Routine inspection (multi-day)·March 8, 2024

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and discussed the purpose of the visit with Administrator Ana Hurtado. The facility was licensed for a capacity of six (6), of which six (6) could be bedridden, and an approved hospice waiver for three (3). During the annual visits, the LPA toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in locked areas. No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon monoxide detectors, facility telephone, fire extinguisher, and a first aid kit wee readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and reviewed multiple staff and client records/files. Technical assistance was provided to the administrator. During the annual inspection, the LPA discovered a staff member, who was witnessed providing care and supervision, was not background cleared. A review of the Departments Guardian system did not reveal a clearance for Staff #1 (S1). This deficiency was cited in an LIC 809D, a civil penalty was assessed, and a Plan of Correction was jointly formulated with Administrator Hurtado. (See LIC 809C for continuation of report.) An exit interview was conducted with Administrator Hurtado, to whom a copy of this report, LIC 811, and the Licensee/Appeal Rights (LIC9058), were provided.