Routine inspection·December 26, 2024

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Dhorydell Sison. During the visit, LPA observed 4 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. While touring the bathroom next to bedroom #2, LPA observed the sliding shower door was stuck. ADM stated she doesn't know how long its been stuck. LPA also observed the screens in the bathroom windows between bedroom #3 and & 2 had dirt/grime on the screens (Photographs were taken.) While touring the bathroom closest to bedroom #3, LPA observed the sink was clogged. (Photograph was taken.) While touring the outside of the facility, LPA observed the screen door, from the backyard, leading into bedroom #4. LPA observed the screen door had dirt & grime. (Photographs were taken.) Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 111 degrees F in resident bathrooms. Fire extinguisher was serviced in December 24, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. ADM stated she does not have a fire drill log. Page 1 Out of 3. LPA reviewed facility records for 3 residents. LPA requested to review R1-R3's preadmission appraisal. ADM was unable to provide LPA with a copy to review. LPA requested to review R3's needs and Services plan. ADM stated she has not completed R3's Needs and Services Plan. LPA requested to review R1-R3's Consent form, (LIC627C). ADM was unable to provide LPA with a copy to review. LPA requested to review R1-R3's Personal rights of Residents in publicly operated residential care facilities for the elderly (LIC613C), ADM was unable to provide LPA with a copy to review. LPA requested to review R1-R3's Resident Personal Property & Valuables form, (LIC621). ADM stated she has not filled out this form for R1-R3. LPA requested to review R2-R3's ID and Emergency information form ( LIC601). ADM was unable to provide LPA with a copy to review. LPA reviewed facility records for 2 staff. LPA requested to review S1's training records and first aid training. ADM stated S1 has not completed his/her training for 2024 or his/her first aid training either. LPA requested to review S1's SOC341A. ADM was unable to provide S1's SOC341A form. LPA requested to review ADM's documents. ADM stated she has the completed all the required documents but has them on her computer. ADM stated her printer does not work. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing R1's centrally stored medication log, LPA observed the log did not have start dates for 5 medications. (Photograph taken.) While reviewing R3's Medications, LPA observed medication M1 was not listed on the Centrally stored medication log. (Photograph taken.). LPA conducted interviews with 1 staff and 2 residents. During today's visit, LPA followed up on the case management conducted on 7/22/2024. LPA Rai was investigating R4's death at the facility, and was not in hospice services. Based on R4's death certificate, R4's cause of death was probable complication of an existing health condition. LPA provided ADM with a flyer "Important updates to Dementia Care & Miscellaneous Changes, Effective January 1, 2025." Page 2 Out of 3. LPA requested a copy of the following documents: 1.LIC 500, Personnel Summary 2.LIC 308, Designation of Administrative Responsibility 3.LIC400, Affidavit Regarding Client/Resident Cash Resources 4. Liability Insurance 5. Qualifications of Administrator (Certificate) 6. Copy of surety bond 7. Please review your facility program for updates (incorporating new laws and/or regulations) Deficiencies are being cited during today's visit. This report was reviewed with Administrator Dhorydell Sison and a copy of the signed report was provided. Page 3 Out of 3. END OF REPORT.