Routine inspection·November 15, 2024

On 11/15/2024, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Thania Gonzalez who was informed of the purpose of the visit. Administrator, William Lee arrived during the visit and was also informed of the purpose of the visit. The facility has a fire clearance for one (1) non-ambulatory and five (5) ambulatory elderly residents. As of 10/20/2022, the facility has an approved hospice waiver for one (1). During the visit, there was five (5) residents and two (2) staff present. LPA toured the facility with Caregiver Gonzalez and reviewed records. During the tour, LPA observed indoor and outdoor pathways free of obstructions and there were no bodies of water on the premises. Outdoor shaded seating is available for the residents in care. Resident bedrooms had the required bedding, furniture, and functional lighting. Bathrooms had grab bars in the showers. LPA toured the kitchen and observed the facility has more than a two-day supply of perishable foods and seven-day supply of non-perishable foods, all stored in a safe and healthful manner. Medications are secured in a locked kitchen cabinet. LPA also observed a hallway closet filled with additional blankets, linens, towels, incontinent and hygiene supplies. Administrator Lee tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility. Staff present have a criminal record clearance and are associated with the facility. The facility's certificate of liability insurance expires on 11/23/2025. A physical record review revealed Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), and Resident 4 (R4) are receiving hospice services at the facility; therefore, the facility was cited for violation of their current hospice care waiver. Additionally, Administrator Lee showed LPA digital records of R1, R3, R4 and Resident 5's Physician's Reports noting they are all deemed non-ambulatory. This violates the facility's current fire clearance. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Lee along with an LIC 809-D, Confidential Names list (LIC 811) and Appeal Rights.