Routine inspection·February 3, 2025

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a 1-Year Required Visit. Administrator, Angelica Martinez, arrived to facility at approximately 9:20 AM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for five (5) non-ambulatory residents and one (1) ambulatory resident for a total capacity of six (6) residents. Facility has an approved hospice waiver for two (2) individuals. Upon arrival, LPA was informed that there were five (5) Residents in care and three (3) staff members on-site. At approximately 9:30 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation with the exception of one (1) staff member (S3) who had background clearance but was not yet associated with the facility. Please see the attached 809-D regarding S3 not being associated to the facility. At approximately 10:00 AM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 2 story building with 6 Resident bedrooms, 3 resident bathrooms, one shower room, 2 staff rooms, 1 staff bathroom, and common spaces. LPA observed that two (2) of two (2) residents' bathrooms did not have waste receptacles with tight fitting covers. A Technical Violation (TV) was issued for the waste receptacles not being in compliance. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Continued on 809-C... ...Continued from 809 During walk through, LPA observed that facility currently does not have an evacuation chair on-site, but all residents currently live on the first floor. A Technical Violation (TV) was issued for the facility not having a evacuation chair on site. LPA advised Administrator to purchase an evacuation chair in the event they have a resident move into the room located on the second floor. LPA reviewed five (5) resident files. Five (5) of five (5) resident files were found to be well organized and thorough with all required documentation. LPA reviewed four (4) staff files. During staff file review, LPA observed that two (2) staff files did not have or have an incomplete LIC501/Personnel Reports. Please see the attached 809-D regarding missing staff files. Staff files had current First Aid and CPR certification and proper training documentation. LPA spot checked Medication for three (3) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. Facility's fire extinguishers were found to be last inspected September 2024. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility conducts emergency drills quarterly with the last emergency drill conducted 1/15/2025. Administrator's Certificate for Angelica Martinez (70000290740) is current with an expiration date of 04/10/2025 LPA is requesting the following documents be submitted to Community Care Licensing (CCL) by DOB: 3/3/2025 Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Exit interview conducted. Copy of report, LIC809D (Deficiency Page) with plans of corrections, LIC9102s Technical Violations, Confidential Names (LIC811), and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.