Routine inspection·January 26, 2024

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 10:00 a.m. The last annual conducted at this facility was on 12/10/2022. When the LPA arrived, there were two (2) staff and four (4) residents present. The Administrator, Maria Mendez, arrived at 10:19 a.m., and at this time the reason for the visit was explained. Entrance interview conducted. At 10:21 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 10:35 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The knives and sharps were observed stored in a locked drawer inaccessible to residents in care. Cleaning supplies were also observed locked and inaccessible under the kitchen sink. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 10:40 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed to be in compliance and last charged on 07/12/2023. The LPA observed required postings throughout the common space. There is a working telephone on premises. Functioning auditory alarms were observed at the time of the visit. (Report Continued on LIC 809C...) (Report Continued from LIC 809...) GARAGE: The garage is attached to the facility. There is one (1) additional refrigerator with perishable items in good condition. The washer and dryer were observed inside the garage. The LPA observed detergents and cleaning supplies in a locked cabinet inaccessible to residents in care. The facility has a sufficient amount of emergency food and water which was observed to be in good condition. The LPA observed a sufficient supply of Personal Protection Equipment (PPE). BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. The facility has two (2) side gates that self-latch. The LPA observed a swimming pool with gates locked and secured at the time of the visit. BEDROOMS: There are four (4) resident bedrooms. Two (2) bedrooms are single occupancy, and two (2) bedrooms are double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The LPA observed a closet in the hallway with extra towels and linens. RESTROOMS: There are two (2) resident restrooms. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured at 117.5 degrees Fahrenheit at 10:25 a.m. RECORDS: Records review began at 10:48 a.m.; four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were complete. Three (3) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were complete. (Report Continued on LIC 809C...) (Report Continued from LIC 809C...) The last emergency disaster drill took place on 01/03/2024. At the time of the visit, the LPA obtained the following documents: LIC 500 Personnel Report, LIC9020 Client Roster, and a copy of the liability insurance. MEDICATIONS: Medications review began at approximately 1:00 p.m.; medications are centrally stored in a locked cabinet next to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.