Routine inspection·August 16, 2023

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required 1 year inspection. LPA met with Dulce Redford, Licensee and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) clients and a current census of (5). Hospice waiver for (2). 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 sufficient indoor and outdoor space for clients. The fenced facility has self-latching gates and covered outdoor patio. LPA inspected the kitchen. The refrigerator and freezer are operating in a safe and healthful manner. Hot water temperature is maintained at 109 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of clients in care. Facility has sufficient cups, plates, and utensils for client use. LPA inspected client bedrooms. Bedrooms are equipped with beds, linen, nightstands, chairs, storage space and sufficient lighting. LPA inspected client bathrooms. Bathroom equipment is operating in a safe and sanitary condition. The hot water bathroom temperatures tested between 105 and 108 degrees F. LPA observed the facility is equipped with operating smoke alarms and fully charged fire extinguishers. Facility has operating telephone service on the premises. Posters such as ombudsman contacts, emergency phone numbers, and evacuation plan are posted in a common area. Sharps, disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to clients in care. Facility has sufficient supply of personal hygiene products, linen, towels, and emergency supplies for clients in care. Client medications are kept in a safe and locked cabinet inaccessible to clients in care. All medications are labeled and administered as prescribed. LPA reviewed (3) staff files for first aid certifications, fingerprint clearances/exemptions, health screenings, training, and personnel records. (3) of (3) staff did not have the appropriate training and health screening. (1) out of (3) staff did not have the proper criminal background clearance. LPA observed Administrator certification is expired. Deficiencies cited. All client records reviewed had admissions agreements, physician's reports, personal rights: Residential Care for the Elderly, and safeguarded cash resource records. An exit interview was conducted, where reports (LIC809 & LIC809D) were discussed and a copy the reports with appeal rights was provided to the Licensee at the conclusion of the visit.