Routine inspection·April 11, 2024

On 4/11/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Maria Lucas and introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in care who are in the facility. The facility has 6 bedrooms, 3 bathrooms, kitchen, dining area, living room, family room, laundry room, medication room, attached garage, and backyard with a shed. 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 74 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed a urinal inside a resident's bedroom with urine inside and not discarded. Deficiency issued. LPA inspected resident bathrooms; bathroom were clean and appliances were found functional. Water temperatures tested at 110.1 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA observed a broken bedroom closet; medication accessible in the kitchen drawer, refrigerator and residents bedrooms; knives in kitchen sink and drawers; chemicals underneath the kitchen sink and inside the accessible laundry room; and dust accumulated in residents bedrooms. Deficiency issued. There was a designated storage space for resident/staff files and medication. There is no swimming pool, bodies of water, guns or ammunition in the facility. Food Service : Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard, and 1 shed used for storage. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed incomplete resident records: outdated physician's reports and missing personal rights forms. Deficiency issued. LPA observed a bedridden resident record without an approved fire clearance. Deficiency with civil penalty issued. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed the emergency disaster plan not reviewed/outdated since 04/20/09. Technical violation issued. LPA discovered that the facility has not been conducting disaster drills. Deficiency issued. Deficiencies, one technical violation and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421IM and appeal rights were discussed and copies were provided to the administrator, Maria Lucas.