Routine inspection·October 28, 2024

An unannounced Annual visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. McClurg. LPA was greeted @ door by Caregiver 1 (CG1) Anterlyn "Lyn" Molina. LPA introduced self, stated purpose of visit, provided business card & was allowed entry. CG1 called Licensee/Administrator (L/A) Davilyn Manilla to notify that LPA was at facility. LPA spoke with L/A over phone, greeted L/A, stated purpose of visit, & inquired if L/A would be able to join LPA for visit. L/A arrived at facility afterwards & joined LPA during mid-physical plant tour. Facility does not have any bodies of water such as pool, spa, fountains, etc. Facility has a wood buring fireplace that is not in use & is blocked from view & use by large wallhanging. When LPA entered facility, residents were observed in living area of dining room watching television. LPA greeted residents. CG1 stated that residents had just completed lunch. Caregiver 2 (CG2) Tereza Molina was at dining table eating. L/A was contacted. LPA began physical plant tour inviting CG1 to accompany L/A. Physical plant toured. Tour began in hallway & proceeded through laundry room. Laundry appliances observed to be in use, with no laundry detergent, etc. accessible to residents. Garage accessible through laundry room. Glass cleanser observed accessible on open shelf under sink in garage. Cleanser made inaccessible @ time of visit. Over/under freezer/refrigerator labelled as "staff food". It was later determined that this appliance did contain food for resident use as well. L/A cautioned about circulating freezer items so as ice accumulation to prevent significant amount of icing to occur & to prevent freezer burn. Resident bedrooms off of hallway toured. Bedrooms sufficiently furnished with adequate lighting. All bedrooms, including front bedroom off of facility entryway, have doors that open to backyard or side yards. Each exit door appropriately identified with Exit sign. Auditory alarms on all exit doors, including door between garage & laundry room. Auditory alarms signals in the kitchen/dining/living room area alerting staff to location of open exterior door. Continued. Continued. Facility has 2 bathrooms. Both bathrooms appeared to be clean with no unpleasant odors. Fixtures operational. Grab bars in toilet & shower areas. Non-skid mat in roll-in showers. Hot water measured at 110 degrees F. Front/hallway bathroom (bath1) identified by L/A as the "staff" bathroom. Shower area used primarily by staff only, with toilet available to visitors, & occasionally by residents when toilet in bath2 is in use. Master bathroom (bath2) off of master bedroom identified by L/A as the "resident" bathroom. Majority of toileting & all showers done in this bathroom. Access to Bath2 is through master bedroom. Staff bedroom opposite bath1. Bedroom unlocked making contents accessible, including spray body mists, 2 bottles of room freshener liquid, eye drops, & acetone nail polish remover. Other personal items observed in clear box with locking mechanism making contents inaccessible to residents. Hazardous items made inaccessible @ time of visit. Baseboards throughout facility in need of dusting/cleaning. All ceiling fan body & blades in need of dusting - significant accumulation of dust/fuzz observed. Air filter cover also in need of dusting/cleaning. Air filter in need of replacement. Toilet paper roll holder in need of tube mechanism. Kitchen toured. Freezer side observed to be over-full to point of compromising circulation required. In door of refrigerator, an over half-full bottle of Pepto-Bismol observed accessible. Medication made inaccessible @ time of visit. Continued. Outside area toured. Access through sliding glass door off of dining/living room onto covered patio. Seating & table available. Backyard & side yards have rose buses. Both side yards have gates. Gate on "southwest" side of building is self-closing & self-latching. Front room egress opens directly onto this area. Other egress at back & on opposite side yard that has gate that is not self-closing & self-latching. Passageway to gate that is not self-closing/self-latching is clear & free of obstruction. This passageway is also cemented from back to front allowing steady surface for walking, walkers, & wheelchairs. "Southwest" side yard with access to gate that is self-closing/self-latching is obstructed with rose bushes & does not have a solid surface to walk on, leaving it to be muddy &/or difficult terrain to navigate with unsteady gait, walker, &/or wheelchair. Discarded mop/mop-like item observed on ground in back corner of backyard. Item removed @ time of visit. Outside yard, including front, maintained & free of any other debris. Medications observed to be locked. Smoke detectors tested& observed to be operational. Carbon monoxide detector operational. Fire extinguisher service date: 7/2/2024. Deficiencies issued. Exit interview conducted with L/A. Report provided.