Routine inspection·August 25, 2023

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Lisa Tolentino, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (5). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Facility has sufficient indoor and outdoor space for client activities. Facility has a covered outdoor patio area sufficient for clients in care. LPA inspected the kitchen. The refrigerator and freezers are operating in a healthful manner. Hot water temperature is maintained at 110 degrees F. Facility has sufficient non-perishable and perishable food supply for clients in care. Facility has sufficient cups, plates, and utensils for client use. Facility food is stored in a safe and healthful manner. LPA inspected client bedrooms. Bedrooms are equipped with beds, linens, nightstands, chairs, and sufficient storage space and lighting. LPA inspected client bathrooms. Bathroom equipment is operating in safe condition. Bathroom hot water temperatures tested between 105 and 106 degrees F. LPA observed the facility is equipped with operating carbon monoxide alarms. Facility has operating telephone service on the premises. Posters such as evacuation plan, complaint telephone number, emergency phone numbers are posted in a common area. Fireplace is adequately screened. Facility has a complete first aid kits. Facility has sufficient linen, emergency supplies, and personal hygiene products for clients in care. Facility has operating door signaling devices and night time supervision. Sharps, disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to clients in care. Client medications are kept in a safe and locked cabinet inaccessible to clients in care. All medications are labeled and record of medication administered to clients are kept at the facility. LPA reviewed staff files for first aid certifications, fingerprint clearances/exemptions, health screenings, training, personnel records. Facility did not have documentation of (1) staff required training on file. LPA reviewed client files for admissions agreements, physician's reports, assessments, personal rights, and record of client personal valuables. All client records reviewed had the required documentation. Deficiencies were cited during today's visit and proof of corrections were discussed with the Administrator. An exit interview was conducted, where reports(LIC809/LIC809-D/LIC9102) were discussed and copies with appeal rights were provided to the Administrator at the conclusion of the visit.