Routine inspection (multi-day)·July 30, 2024

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct an annual continuation from 5/31/2024. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Joselito Carambas. Licensee Monica Siharath arrived 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, 2 ambulatory and 4 non-ambulatory. 2 residents were receiving hospice services. The Administrator for the facility is Brandon Navasak and their certificate was valid and current. During visits on 5/31/2024 and 7/30/2024, 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. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 133.0 degrees Fahrenheit in a private resident bathroom and 120.7 degrees Fahrenheit in a common bathroom. Licensee turned down the water heater during the visit and the water was remeasured at 119.8 degrees Fahrenheit before the end of the visit. The facility’s internal temperature was measured at 76 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Monica Siharath, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of 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 residents 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 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, documents regarding safeguarding personal property and personal rights. 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 Licensee will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. The following deficiency was cited for hot water temperature and noted on the attached LIC809-D page. An exit interview was conducted with Licensee Monica Siharath, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).