Pre-licensing visit·May 26, 2023

Licensing Program Analysts (LPAs) Melody Brown and Mary Rico conducted an announced visit to the facility for purpose of a Change of Ownership evaluation. At approximately 10:00 AM, LPAs met with Administrator Shreeta Yadav . An initial application for change of ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 04/27/2023 for a total capacity of 6 with five (5) non-ambulatory and one (1) bedridden. Fire clearance was granted on 02/28/2023. LPAs Brown and Rico observed the following: Structure: Facility was a one (1)-story house with four (4 )resident bedrooms, one (1) resident and one (1) staff bathroom, living room, dining area and kitchen. There was an attached one car garage in the right backside of the house. Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house. Bedrooms: Each resident bedrooms accommodate five (5) non- ambulatory and one (1) bedridden resident. Three (3) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm. However, one (1) resident bedroom have no closet. Bathrooms: The one (1) resident and one (1) staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 11:10 AM, LPAs tested the water temperatures in the resident bathrooms. LPAs verified water temperature was measured at 109 degrees Fahrenheit. ***CONTINUED ON LIC 809-C*** *** This is an amendment of the LIC809 issued last 05/26/2023 *** ***CONTINUED FROM LIC 809*** Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. LPAs observed residents medicine in unlocked kitchen drawer prepared ahead of time, in a predispensed container with resident name. LPAs requested Applicant Yadav to immediately remove and locked away the predispensed medications found in the unlocked drawer. There was adequate room for food storage. LPAs observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the garage. Laundry detergents and cleaning supplies were observed in garage, garage door is locked away from residents. Living/Family room: There was a living/family room with adequate seating for all residents and a working TV. Linens and Hygiene Supplies: An adequate supply of linens was stored in a cabinet in the main hallway of the residence. Yards/Outside: Patio furniture for outdoor seating observed. Self-latching handle on right side of the house that leads into the backyard. There is a gate on the back right side with an exit in the front of the house. All outdoor pathways were free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch were observed posted in the dining room and small hallway. There was Ombudsman poster and Let-Us-No poster observed. General items: Two (2) fire extinguishers were charged and located in the kitchen and resident bedroom. Eight (8) smoke alarms and one (1) carbon monoxide detector were tested and were observed to be in working order. Resident records were stored in a locked cabinet in the garage. First Aid kit with required components, and locked area for medication storage was observed. LPAs observed a facility phone and was operational as evidenced by LPAs dialing the number. The phone number designated for the facility is 909-727-8305. There is enough Emergency water supply observed but LPAs Brown and Rico observed no available required 72-hour emergency food supply and no available resident Emergency Bags at the facility. Component III was completed on this day as well.***CONTINUED ON LIC 809-C*** *** This is an amendment of the LIC809 issued last 05/26/2023 *** ***CONTINUED FROM LIC 809*** Additionally, LPAs observed facility to have required single entry point for COVID screening, upon entering facility. LPAs observed required COVID signages throughout the facility, soap and disposable towels in bathrooms for washing hands. LPAs observed incomplete Activity Calendar for the month for the residents. Moreover, LPAs Brown and Rico observed no Rights of Resident Council Board and Family Council Board were posted in a prominent place at the facility. Pre-Licensing is incomplete and the following deficiencies to be resolved by 06/20/2023 at 10:00 AM. Obtain/Purchase 72-hour emergency food supply for residents Obtain/Purchase 72-hour emergency bag pack for residents Staff Medication Training with Staff Training Log (medications need to be in a locked drawer) Purchase Closet for Resident #1 (R1) and Resident #5 (R5) Post Rights of Resident Council Board Post Family Council Board An exit interview was conducted, and a copy of this report, LIC809 and LIC9102 TA were discussed and provided to Administrator Shreeta Yadav. *** This is an amendment of the LIC809 issued last 05/26/2023 ***