Routine inspection·September 11, 2023

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to staff who were advised of the purpose of the visit and S1 phoned licensee Sushma Lal. Licensee Lal arrived shortly and was also informed of the reason for the visit. The facility is currently licensed as a Residential Care Facility for Elderly, with a capacity of four non ambulatory and two ambulatory residents only. All residents and some visitors are present during today's visit. LPA Bueno and staff Hoyos toured the facility inside while LPA and Licensee toured the exterior of the facility. Licensee left the facility prior to the conclusion of the inspection Buildings and Grounds: The home has 5 bedrooms, two bathrooms, a sitting room/office area, a laundry room, a TV/sitting area, and a kitchen and dining area. The facility has no bodies of water. There is a backyard patio with ample seating. LPA and Licensee observed that the side gate is locked but free of obstruction. The facility has a working telephone available for use. There is charged fire extinguisher. S1 tested resident bedroom smoke alarms and LPA tested hallway carbon monoxide detector. LPA and S1 found all units to be in working order. Storage and Supplies: Activities were observed to be available near the office area and in the TV are. A locked centralized closet is utilized for medications while client and staff files are secured in the office area. The first aid kit was observed to be available and complete. Linens, and equipment are all in good repair and sufficient for approved census. Food Service and Laundry: LPA and S1 observed two days of perishable food items and 7 days of non- perishables. Utensils and dishware are sufficient for the capacity. The refrigerator and stove are in working order. Sharps are kept locked while toxins and cleaning agents are secured in cabinets, inaccessible to residents. Bedrooms and Bathrooms: Resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. LPA and Licensee observed the water temperature to be 109 degrees Fahrenheit. Facility Files and Medication: LPA inspected all resident files and found that it had the required documentation including an admissions agreement and current physician's repor. LPA reviewed three of three staff files with one current first aid certification and two expired. LPA found training records but were not current. LPA reviewed all resident medications and found R1's medication (M1) being administered but is not on the centralized log. Licensee updated personnel report, and will send a current LIC 610E, emergency disaster plan to LPA. Deficiencies which pose immediate and potential health, safety or personal rights risk to residents in care. Refer to LIC809Ds for deficiencies issued during today's visit. An exit interview was conducted by telephone with Licensee and a copy was signed by and provided to S2 at the conclusion of the inspection.