Routine inspection·April 29, 2024

On 04/29/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with staff member (SM), Noralyn Calabines and explained the purpose the visit. LPA asked the SM Calabines call the Facility Designated Administrator (FDA), Tabitha Antonia to inform them that CCL was present at this time. Shortly after, LPA met with FDA Antonia and explained the purpose of the visit. One other staff member was present, Grace Lee. This facility is licensed to serve and retain 6 residents who are 60 or older. All of which may be non-ambulatory. This facility also holds a Dementia Program on file and has a Hospice Waiver for 6. Current census was 4. LPA reviewed 4 resident files and 3 staff files. All files were current and up to date. The administrator has an expired administrator certificate however the LPA was able to verify that the administrator was able to send in the required documents prior to their expiration. The administrator is currently awaiting the department for a renewed certificate. LPA Pascua observed a locked centralized stored medication cabinet located in the dining room. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components. LPA conducted a tour of the facility. The fire extinguisher, located in the kitchen area, was serviced by Jorgenson Company on 01/19/2024. Carbon Monoxide and fire alarms were present and in good repair. Common areas for resident use were toured. Furniture and furnishings were observed to be present and in compliance. A tour of the bathrooms was conducted. Hot water temperatures were taken to ensure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time. Grab bars were present and functional. Resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition. A linen closet was located in the hallway. LPA observed a sufficient amount of linens at this time. The kitchen area was toured. Facility freezer and refrigerator showed to be functional and in compliance at this time. A tour of the pantry was conducted. LPA observed that there was a 2 day perishable and 7-day nonperishable food supply at this time. Garage area was toured. Laundry detergent and cleaning supplies were locked and made inaccessible at this time. First aid kit was observed to be present and contained all of the required components at this time. The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair with no hazards present. The following forms and documents were requested to be updated and submitted into CCL. -LIC 308 -LIC 400 -LIC 500 -LIC 610 No deficiencies were observed or cited during this annual visit. An exit interview was conducted and a copy of this report was given to Facility Designated Administrator.