Routine inspection·August 11, 2023

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Rolando Serquinia, 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) residents. Hospice waiver for 3. 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. Fireplace is adequately screened . Facility has no outdoor bodies of water. Facility has a covered patio area and enclosed with a self-latching back gate. However, facility auditory/alert systems were not functioning properly. Deficiency cited. LPA inspected the kitchen. The refrigerator temperature is maintained at 39 degrees F. Hot water temperature is maintained at 107 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of residents in care. Facility has sufficient cups, plates, and utensils for resident use. LPA did observed the vent above the kitchen stove was soiled with grease and debris. Deficiency cited. LPA inspected resident bedrooms. Bedrooms are equipped with mattresses, nightstands, pillows, chairs, and storage space. Bedrooms have sufficient linen and lighting. LPA inspected client bathrooms. Bathrooms are equipped with handrails and operating in safe and sanitary conditions. The hot water temperatures in bathrooms tested between 105 to 107 degrees F. LPA observed the facility is equipped with operating carbon monoxide alarms and fully charged fire extinguishers. Facility has operating telephone service on the premises. Posters such as personal rights, complaint telephone number, emergency phone numbers are posted in a common area. Emergency drill conducted on 8/4/23. Sharps, disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to residents in care. Client medications are kept in a safe and locked cabinet inaccessible to clients in care. All medication are labeled and administered as prescribed. All staff files reviewed had first aid certifications, fingerprint clearances/exemptions, health screenings training certifications, employee rights and personnel records. LPA reviewed three (3) resident records for admissions agreements, physician's reports, personal rights: residential care for the elderly, record of safeguarded cash resources. LPA observed resident #2 (R2) last medical assessment was in 2019, due to R2's medical condition an annual assessment is required. Deficiency cited. Deficiencies were cited during today's visit and a plan of correction was discussed with the Administrator. An exit interview was conducted, where reports (LIC809 & LIC809-D) were discussed and a copy of the reports with appeal rights was provided to the Administrator at the conclusion of the visit.