Routine inspection·July 18, 2025

Licensing Program Analyst (LPA) De Leon arrived at 10:00 am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Kylan Reynoso and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan to CCL. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. PPE and infection Control Training is done initial upon hire and annually thereafter. All sinks have soap, paper towels, hand washing signs. Physical Plant & Environment Safety: The facility is a 3 bedroom and 2 bathroom home currently occupying 4 residents with 1 bedroom being shared. The facility employs 9 staff and 1 administrator. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility is fully fenced around the backyard with a self closing and latching gate. The facility has a patio with furniture and awning for shade. Laundry room is in the garage and has a working washer and dryer, kept locked with all laundry and cleaning supplies. Operational Requirements: The Facility is operating in compliance with granted fire clearance. The facility is cleared for 4 non-ambulatory with a Hospice wavier granted for 4. The facility liability insurance expires 09/01/2025. Continued 809-C Staffing: The facility employes 9 staff and 1 Administrator. Staff records are kept confidential. Staff records were reviewed for 5 staff for fingerprint clearance and associations, personnel record or application, First Aid and CPR certificates and Health screening with TB results. 3/5 Staff had missing records or files. Personnel Records & Training: The facility keeps confidential files for each staff member. The facility staff are not meeting the required hours and subjects for initial and annual training and are currently scheduled to take all required training's for 2025. Some staff had training records but the records did not met the amount of hours or the required topics. The facility is using Relias online system for 2025 but did not have the records present for the staff at the facility. Administrator Certificate expires 12/03/2025. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), Immunization records, TB results, Personal Rights, and Safeguard for personal property and valuables. The four files reviewed were lacking records and not complete at this time. Resident Rights Information : All require postings were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, Nondiscrimination notice in addition to a CCL Complaint poster. Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines, newspapers, TV watching, daily walks, group discussions and communications and gestures, with games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. The residents attend day programs during the day. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available in the garage. Foods need to be wrapped and stored with lids. Continued 809-C Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 4 residents. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR) and the Medication Administration record. all were up to date, legible and written as prescribed. LPA completed a full audit on four residents medication, all medications were in original containers, prescription labels were not altered, doctors orders were present and dispensing instructions were followed. Disaster Preparedness: The current emergency disaster forms were posted. The fire extinguishers were charged and last inspected 12/18/2024. The smoke detectors and carbon monoxide detectors are present. The facility does conduct disaster drills at facility but records were not up to date for the last 4 quarters. Residents with Special Health Needs: The facility has submitted a updated plan of operation to accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility does not have delayed egress. The facility does not have any residents with oxygen. The facility does not currently have any residents on hospice and home health services. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.