Follow-up·November 21, 2023

Licensing Program Analyst (LPA) Alviso conducted a case management on 11/21/23 at approximately 9:15am, and met with caregivers Rhonel Recinto and Mary Grace Bustas . Case management is being conducted as the Licensee is requesting an increase in capacity, from six (6) to nine (9) residents. There are currently six (6) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. Fire clearance is approved for nine (9) non-ambulatory, which includes two (2) bedridden approval, effective 10/17/23. All exits were free and clear of obstruction. Fire extinguishers, (2), were serviced and tagged as required. LPA observed fifteen (15) smoke alarms, including carbon monoxide detector. All exit doors had auditory alarms, and the alarms were working properly during the inspection. The front of the facility entry has a large cement porch area with a ramp for resident use, and across from the ramp is an open area with two steps off of the porch, there is no self latching gate at this area. Licensee will continue to ensure residents accessing the front of the facility's cement porch area are supervised as needed and required, due to the open area with steps. This is a health and safety concern, Licensee has stated a self latching gate will be installed due to the safety concerns. Licensee to notify Licensing Department when this is complete. Licensee to ensure the facility sketch is updated and submitted to the Licensing office, by 11/22/23; LPA will notify the local Fire Department to come out and reinspect due to the changes, since last visit of 10/19/23, to the facility's outside physical plant. The facility's increase in capacity, from six (6) to nine (9) residents is approved today, 11/21/23. No deficiencies cited today.