Routine inspection·March 12, 2024

Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced annual visit. LPA met with the Administrator, Monina Arjona and explained the purpose of today’s visit. A tour of the facility was conducted inside and out. The facility is a (6) bedroom, (3) bathroom one story home. Tour included: Physical Plant: The tour of the front entrance, interior and exterior surroundings was observed to be in good repair with no pathway obstruction and facility's water temperature measured above 120 degrees however hot water was adjusted accordingly. LPA observed a warning sign for hot water was posted in each bathroom. LPA inspected each residents room and observed them to be clean, odor free, and furniture in good condition. The inspection also revealed sufficient lighting, bedding and mattress pads in residents’ bedrooms. All furniture throughout the facility was in good condition. Smoke and carbon monoxide detectors were also inspected and found to be in working order. All cleaning solutions were observed in a locked secure area. Facility does not house firearms and/or ammunition on grounds. Food Services: 7 day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents. Items reviewed/discussed: Staff present have a criminal record clearance in file and are associated to the facility. LPA conducted interviews with staff and residents. Last emergency drill was conducted on 12/1/2023. Facility, staff and residents' records were reviewed and all required documents were present and up to date. All required postings were posted throughout the facility. LPA observed the medications and medications are dispensed according to physicians instructions, however the following deficiencies were observed: - The facility's record keeping system of medication dosages given to residents was not up to date from January 1, 2024 to present. Deficiency cited. -The facility's record keeping system of PRN medication dosages given to residents was not up to date from January 1, 2024 to present. Deficiency cited. An exit interview was conducted with Administrator Arjona Monina and a copy of this report, LIC 809D, LIC 811 and appeal rights were discussed and provided.