Routine inspection·January 12, 2024

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted by staff who was informed of the purpose of the visit. Staff notified Licensee of LPAs arrival and Licensee arrived during the visit. LPA toured the interior and exterior of the home with staff and then with Licensee. Physical Plant and Operational Requirements: LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature was measured and Licensee made corrections during today's visit to ensure compliance. Cleaning supplies and hygiene provisions are kept locked and secured. Fire extinguishers were observed to be charged and last inspected on 01/10/2023. LPA tested carbon monoxide detectors while Licensee tested interconnected smoke alarms and all were found in working order. All outdoor and indoor passageways and ramps are free of obstruction. A locked area is provided for medications and sharp objects. There is a working telephone at this location. The LIC 610E and emergency client files are maintained. Licensee presented current plan of operation and admission agreement. LPA observed Resident rights, house rules, and complaint posters and grievance procedures are posted in the facility. Resident Files, Personnel Files/Training, and Medication Records: LPA reviewed centrally stored medication list and all scheduled and PRN medication and found that they were administered as prescribed. Neither resident nor staff records were unavailable for review during today's inspection. This poses a potential health and safety concern for residents in care. All records shall brought into the Regional Office no later than end of business of correction date for LPA Bueno to review. Food Service: LPA was present during lunch time. The meal is adequate to meet the nutritional needs of the residents. Kitchen and dining areas were kept clean and organized. Food supply meets the requirement of 7 day supply of nonperishable and 2-day supply of perishables food items. Refer to LIC 809D for cited deficiencies and technical violations for issues related to deficiencies. An exit interview was conducted where this report, LIC 809D, LIC9102A, and appeal rights were discussed and copies provided to Licensee. Additional technical notes were provided electronically to Licensee.