Routine inspection (multi-day)·May 17, 2024

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management Annual Continuation visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Jay Elevado. LPA spoke with Administrator Siera Navasak via phone during the visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 6 residents, 4 of which were non-ambulatory. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Siera Navasak and their certificate is pending. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. The facility’s water temperature was measured at 106.9 degrees Fahrenheit in a common bathroom and 106.5 degrees Fahrenheit in a private resident bathroom. LPA observed broken tiles and exposed insulation in the private resident shower and according to staff, the shower wall has been broken for at least 1 week and staff are still using the shower to bathe residents. The facility’s internal temperature was measured at 72 degrees Fahrenheit. LPA observed cleaning chemicals stored in unlocked cabinets in the facility kitchen and a private resident bathroom. Staff relocated the cleaning chemicals to locked storage during the visit. According to Elevado, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. LPA observed that resident medications were pre-poured into weekly pillboxes and were not in their original container. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. Continued on LIC809-C page… Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, and documents regarding safeguarding personal property. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. The Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. The following deficiencies for facility disrepair, pre-poured medications, and unlocked cleaning chemicals are being cited and noted on the attached LIC809-D pages. An exit interview was conducted with Caregiver Jay Elevado, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).