Routine inspection·September 24, 2024

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required inspection visit for this facility and was greeted by Lead Staff, Arlene Ponce De Leon. Licensee, Annabelle Lewis-Barreto was contacted but was unable to attend the visit. The facility is a single story building licensed for 4 non-ambulatory residents. The facility currently provides care for 3 residents, all of which were present during inspection. There are currently no residents receiving hospice services but some of which have a diagnosis of dementia. LPA continued with a tour of the facility with Lead Staff (Designee), facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 2/26/2024. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food supplies in the garage. Facility also follows appropriate dietary protocol for resident in care. Toxins were located in the garage and laundry room both of which were found to be secured. LPA toured the facility backyard and found all bedroom screens in good repair and found one emergency exit located in the side yard to be clear and unobstructed. Two storage sheds located in the backyard were also found to be locked and secured. Residents were observed in their bedrooms watching television and preparing for following day’s outings. There was a supply of hygiene products and paper products available for residents. All resident bedrooms have lighting & appropriate furnishings. Water at faucets accessible to residents was measured within regulation. Medications located in dining area were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Store Medication Record. Upon medication count LPA found all administered medication to be in order. Continued onto LIC809-C Continued from LIC809 LPA conducted a file review for all 3 out of 3 residents and found all items including Physician's Reports and Needs & Service Plans to be updated. The facility conducts quarterly assessments for each resident or upon changes of condition. LPA and Lead Staff/Designee conducted a spot P&I count for residents and found all monies to be in order and not commingled. LPA was unable to complete today's inspection of Staff files and will return at another time.