Routine inspection·August 16, 2023

On 8/16/23 at 10:30 am, Licensing Program Analyst (LPA) Chavez made an unannounced Annual/Required visit to the facility listed above. LPA met with Staff #1 (S1), caregiver, and explained the purpose of the visit. At approximately 11:30 am, Diana Barnhill, Licensee/Administrator, arrived at the facility. A tour of the physical plant was assessed, and the following was noted: LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights in the front entry. Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, all in good condition. The facility maintains a comfortable temperature. The smoke detectors are hard-wired, and carbon monoxide detectors were tested and operational. Fire extinguishers (2) located in the kitchen were inspected on 8/4/23 and are charged in the green. There are no issues with Fire Clearance. Living room and dining room furniture were checked and in good condition. The common rooms are clean, safe and sanitary. The courtyards of the facility have outdoor furniture with shaded area for residents. The facility has two wooden gates on each side of the perimeter. The gate on the north side closes only if aggressively pushed and does not automatically close. Technical violation issued. The facility also has two rod iron fences and gates with latches on the outside disabling residents from opening the gates easily. Residents would have to reach over the gate to open. Technical violation issued. Licensee will relocate the latches to inside the gates and will send LPA photos by 8/23/23. The kitchen is sufficiently stocked with two-day perishable and seven-day non-perishables. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Refrigerator is kept at 45 F degrees. Technical violation issued. The freezer measured at 0 F degrees. The kitchen has a cabinet under the sink without a lock containing dish soap and powdered bleach. Deficiency cited. Staff immediately moved the items to a locked cabinet. Continued on 809-C. The kitchen's stove has knobs (6) attached and the kitchen is accessible to residents in care. Deficiency cited. Approximately 4 knives and a pair of scissors were observed in an unlocked kitchen cabinet above the oven. The kitchen is accessible to residents in care. Deficiency cited. Resident rooms are adequately dressed with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and sufficient lighting for each resident. There is enough linen available to change regularly. Storage cabinets have sufficient amounts of personal hygiene product which is provided by the licensee. Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 114.6 F and 115.1 F degrees in resident bathrooms. Infection Control : Licensee states that staff wash their hands after taking gloves off but does not wash hands prior to placing gloves on. Technical violation issued. Medications are centrally stored in locked storage cabinets behind the living room. Medications are properly labeled and checked for expiration dates. A sampling of residents’ medicationa show they are centrally stored prescription and PRN medication which have been logged in the medications record with proper documentation from the residents’ doctors. Proper medication dispensing instructions are followed and checked for contamination. First Aid kit has all proper items and is current. Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. One resident needs their Appraisal, Needs & Services Plan signed, and dentist information entered on their Identification and Emergency Information sheet. Another resident who moved in last week needs an Appraisal, Needs & Services Plan completed. Licensee will ensure these items are complete and send to LPA by 8/23/23. Planned activities are offered to residents in care. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations and current First Aid. S1 did not have a background clearance. LPA instructed Licensee to have S1 leave the property and return only when clearance has been obtained. Deficiency cited, civil penalty issued. The first aid certification for Staff #2 (S2) expired on 11/20/22. Deficiency cited. Five out of five staff records reviewed indicate annual training was not completed. Deficiency cited. The Administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate. Continued on 809-C. Quarterly emergency disaster drills have not been completed. Records show a drill was conducted on 7/15/23 and no prior documentation on drills. Deficiency cited. Emergency Disaster Plan has an incomplete Section C, page 6. Technical violation issued. Licensee states the facility had a bus to transport residents, however, they no longer have the bus and would transport residents in an emergency with staff vehicles. Emergency disaster plan needs to be updated to reflect as such. Technical violation issued. Facility has two residents using oxygen with tanks in their rooms. Signage is present, however, Licensee states the fire department has not yet been notified. Technical violation issued. Licensee will notify the fire department and send documentation to LPA by 8/23/23. Liability Insurance : Licensee states she has liability insurance but does not have documentation showing the coverage. Deficiency cited. Licensee will send LPA proof of liability insurance by 8/23/23. Exit interview conducted, deficiencies cited, and civil penalty given, technical violations issued, and the report and appeal rights given.