Routine inspection·June 19, 2024

On 06/19/2024 at 09:20 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 Licensee/Administrator Ebraheem Hamed and was granted entry to the facility. At the time of the visit there was two (2) staff present, and sixteen (16) residents present. LPA Brown explained the purpose of the visit to Licensee/Administrator Ebraheem Hamed. The facility is eleven (11) bedroom, seven (7) bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of twenty-two (22) ambulatory residents. The current census is twenty-one (21) residents. LPA Brown was accompanied by Licensee/Administrator Ebraheem Hamed 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 72 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 and non-skid mat in the resident bathrooms. Moreover, during the tour of the facility, LPA Brown observed the knives drawer not locked and accessible to residents in care. Deficiency will be issued. In addition, LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 113 degrees Fahrenheit. LPA Brown observed one (1) window screen in disrepair. Technical Violation issued. LPA Brown observed movable waste bin in the kitchen does not have a cover. Deficiency will be issued. ***Continuation in LIC809C *** 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. Also, LPA Brown observed that the facility does not have signal system. Deficiency will be issued. All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the Office room. Food Service : Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. Care & Supervision : The facility has an administrator present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care. Record Review : LPA reviewed eight (8) resident files for pre-placement appraisals, admission agreements, updated physician reports, and needs and services plans. LPA Brown observed five (5) of eight (8) files reviewed for physician’s reports do not have Physician signature date. Deficiency will be issued. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown found that Staff #2 (S2) and Staff #4 (S4) do not have Health Screening Report and Tuberculosis Test Result in their facility file as there's no physician signature in their Health Screening Reports. Deficiency will be issued. Furthermore, LPA Brown observed Staff #2 (S2) and Staff #4 without current cardiopulmonary resuscitation (CPR) training and first aid training Deficiency will be issued. Lastly, LPA Brown did not observe required trainings provided to the staffs at the facility. Deficiency will be issued. Also, three (3) residents medications were audited and LPA Brown observed that there's one medication not listed in Resident #2 (R2) Medication Administration Record (MAR) at the facility and LPA Brown observed that the facility's dispensing or giving R2's medications. Deficiency will be issued. To add to that, LPA Brown observed that Resident #9 (R9) medication was dispensed/given but Staff #2 (S2) did not sign/update R9's MAR. Deficiency will be issued. An exit interview was conducted where this report, (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to Licensee/Administrator Ebraheem Hamed.