Routine inspection·February 14, 2024

On 02/14/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met caregiver, Lily Mayo and introduced self and stated purpose of the visit. LPA was informed that there are currently 10 residents in care who are in the facility. The facility has 3 buildings: building #1 has 7 resident bedrooms, 1.5 resident bathrooms, 1 staff room, kitchen, dining area, entry room, living room, laundry room, backyard with 1 shed; building #2 has 3 resident bedrooms, 1 bathroom, entry room, kitchen, living room, laundry room, backyard with 1 shed; building # 3 has 2 resident bedrooms, 1 resident bathroom, kitchen and living room. LPA completed a walk through of facility and review of records. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 and 72 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 120 and 114.1 degrees fahrenheit. The facility is equipped with carbon monoxide alarms, fire extinguisher and first aid kit. LPA observed 5 smoke detectors in building #1 not functioning, 1 smoke alarm in building #2 not functioning and the ceiling in the living room for building #2 broken. Deficiency issued. Posters such as; the ombudsman and emergency disaster plans were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. LPA observed the medication moved from its original containers and placed on a small cups ready for the current day dispensing. Deficiency issued. There are no guns or ammunition in the facility. LPA observed the telephone in building #1 not functioning. Deficiency issued. Food Service : Non-perishable and perishable food supply is sufficient for number of residents in care. Dishes, cups, and utensils were also stored properly. Yards/Outside: Three shaded patios, a gate with self-latching handle on the front and back side of the house and 2 sheds used for storage. All outdoor pathways were free of obstructions. Record Review: LPA reviewed 5 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that there was one staff file missing and a missing cpr certification for another staff. Deficiency issued. LPA observed that the posted administrator's certificate expired on 7/13/22. Deficiency issued. The facility did not have the emergency drills log available for inspection. Deficiency issued. LPA observed that the administrator did not have an appointed and approved representative during their vacation absence. Deficiency issued. LPA observed that the posted emergency disaster plan has not been reviewed and updated since 5/14/18. Deficiency issued. LPA observed that the facility did not have a copy of the Infection Control Plan available for inspection. Deficiency issued. LPA observed that the residents bedrooms in building #1 did not have oxygen signs posted and the facility did not have record of the notice sent to the local fire department. Deficiency issued. LPA also observed that the administrator did not have a copy of the liability insurance available for inspection. Deficiency issued. Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to caregiver, Lily Mayo.