Routine inspection·May 5, 2023

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Mary Jane Mendoza. There are currently 5 residents living in this facility. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 2 of the residents and none of the residents are approved for bedridden. LPA toured facility and grounds and observed facility was found to be clean at a comfortable temperature with all exits free from obstruction. Resident rooms have the required furnishings and linens. Medications are stored locked in a locked cabinet in the living room area along with resident files. LPA reviewed medications and consulted regarding additional documentation needed if the facility is not going to use the Medication Administration Record (MAR). LPA will return to review changes made and to provide additional guidance per regulations. Facility has at least two days of perishable and one week of non-perishable foods. Fire Extinguisher was found to be charged, and serviced 5/30/2022. Smoke alarms and Carbon monoxide detector are operational. Facility last fire drill was conducted on January 2023. Facility has awake staff during the night as there are no rooms available for staff to sleep in. Water temperature in bathrooms measured at 107 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. LPA reviewed all resident files, and some staff files and staff files had the required training and proof of CPR/1st Aid expiring 9/2/2023. Resident files were reviewed and some appraisals were signed but not dated. Facility was advised to get the required signatures and/or redo reports. Continue report see LIC809-C Outside yard was observed with no hazards, LPA requested facility to service both side yard gates as the weather has affected them. Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan. Licensee/Administrator to submit the current following documents by 6/5/2023: · LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan · LIC 9020 Register of Facility Residents Infection Control Plan of Operation (If changes) Liability Insurance Copy of current Lease Agreement No citations issued during todays visit.