Routine inspection·April 29, 2024

On 04/29/2024 at 11:00 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there was two (2) staff present, and five (5) residents present. House Manager Leofel Capulong and Administrator Paul Krause were contacted and arrived during the visit. LPA Brown explained the purpose of the visit to House Manager Leofel Capulong and Administrator Krause. The facility is a five (5) bedroom, three (3) bathroom home with a kitchen/dining area, living room, laundry area and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents of which one (1) may be bedridden. The facility has two (2) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Staff #3 (S3) to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant : The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars but no non-skid mat in the resident shared bathroom. Deficiency will be issued. Also, LPA Brown observed Resident #2 (R2) with half bed rails and House Manager Leofel Capulong reported to LPA Brown that R2 does not have a written order from R2's Physician indicating the need of half bed rail for mobility. Deficiency will be issued. ***Continuation in LIC809C *** Moreover, during the tour of the facility, LPA Brown observed two (2) over the counter ointments in the kitchen drawer, not locked, accessible to residents in care. Deficiency will be issued. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 106 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster, Labor Laws and the Emergency Disaster plan were posted in a common area. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the hallway. LPA Brown observed no planned activities for the residents at the facility. Deficiency will be issued. Food Service : Seven (7) days non-perishable and three (3) days perishable food supplies were observed at the facility. LPA Brown observed that the facility has set Weekly Menu posted. Care & Supervision : The facility has an administrator present. LPA Brown observed that the facility have dementia residents per documents review and they do not have night supervision as there's no staff scheduled to work at night, awake and on duty. Administrator Krause confirmed that there's no staff assigned to work at night shift. Deficiency will be issued. Record Review : LPA Brown observed no Infection Control Plan at the facility. Deficiency will be issued. LPA reviewed three (3) resident files for admission agreements, updated physician reports, Preplacement Appraisal and Appraisal Needs and Services plans. LPA Brown observed Resident #1 (R1) Physician Report (LIC602) is incomplete as it's missing two (2) pages and without the Physician signature. Deficiency will be issued. Also, Resident #2 (R2) Preplacement Appraisal (LIC603) does not have Licensee/Administrator signature. Technical Violation issued. In addition, R2's Admission Agreement does not have Resident/Responsible Party and Licensee/Administrator Signature. Deficiency will be issued. Moreover, Resident #3 (R3) does not have updated Physician Report (LIC602) and per documents review, R3 has dementia and LPA Brown observed R3's physician signature date on 02/26/2020. Deficiency will be issued. Furthermore, LPA Brown observed that the Licensee/Administrator did not complete the required Needs and Services Plan for R1, R2 and R3. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA found that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) do not have completed Health Screening Report by their Physician. Deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to Narissa Geronimo and Administrator Paul Krause.