Routine inspection·September 23, 2023

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:03AM. LPA met with facility Administrator Lourdes Ricafort and discussed the reason for today's visit. Entrance interview conducted. At 09:27PM, LPA, along with 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. The following was observed: Fire Extinguishers were observed to be fully charged and last serviced on 06/07/2023. Separate carbon monoxide detector and smoke detector were tested at 12:39PM and 12:40PM and functioned properly. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. The garage was observed to be locked and contained extra food, separately stored cleaning supplies and storage for additional items. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Outdoor shed was observed locked. Exit route was observed to be clear and free from hazard. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are for resident use and 1 (one) is designated as a staff room. RESTROOMS: The LPA observed 2 (two) restrooms in the facility; 1 (one) is a shared resident restroom located in the hallway and the other is a private resident restroom attached to a vacant resident room. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Report Continued on LIC 809-C Water temperature was measured in common resident restroom and measured within the required range. KITCHEN : Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency supply. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. RECORD REVIEW: Began at 09:45AM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 1 (one) resident record reviewed (Resident #1 - R1) has a dementia diagnosis, but the medical assessment has not been completed annually. Technical violation issued. 3 (three) staff files reviewed and were observed to be in compliance with regulation at the time of the visit. MEDICATION REVIEW: Began at 12:13PM. Medications for 2 (two) residents were reviewed, as 1 (one) resident is able to manage their own medications. All medications reviewed were stored and documented in accordance with regulation. EMERGENCY DISASTER PLAN: The facility's emergency disaster plan was reviewed during today's visit. The facility is utilizing an outdated copy of the LIC form, but required information was observed to be documented elsewhere. LPA will provide Administrator the updated form. Disaster drills are conducted quarterly, with the last documented drill on 08/01/2023. INFECTION CONTROL PLAN: During today's visit, the LPA reviewed the facility's infection control plan. The facility's policies and procedures related to infection control are adequate. No citations issued. Exit interview conducted with Lourdes Ricafort. Today’s reports were reviewed and provided.