Routine inspection (multi-day)·May 7, 2024

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced 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 Administrator Siera Navasak. 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, 3 were non-ambulatory and 3 were ambulatory. 2 residents were on hospice services. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Siera Navasak and their certificate was incomplete. 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 was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 106.5 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 70 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Siera Navasak, 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 label. 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. 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. Continued on LIC809-C page… LPA reviewed multiple resident and staff records. Review of residents' records revealed that 3 of 6 residents had a diagnosis of dementia and did not have an updated medical assessment conducted within the last 12 months. [Administrator was provided with LIC811 Confidential Names List to identify the 3 residents] 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 deficiency was cited for updated medical assessments and noted on the attached LIC809-D page. Technical violations for business entity status and Administrator Certificate were also issued and noted on the LIC9102TV forms. An exit interview was conducted with Administrator Siera Navasak, whose signature below confirms receipt of a copy of this report, the LIC811, the LIC9102TVs, and the Licensee Appeal Rights (LIC9058 3/22).