Routine inspection·December 15, 2023

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:46PM. LPA met with Licensee/Administrator Edna Dangiapo. Entrance interview conducted. Beginning at 12:48PM, the LPA, along with Licensee/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: Smoke detector was tested at 02:45PM and carbon monoxide detector was tested at 02:45PM and both were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 03/16/2023. BEDROOMS: There are 6 (six) total bedrooms; 1 (one) of which is a shared resident room, 4 (four) are private resident rooms and 1 (one) is designated as a staff room. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Staff room was observed to be locked. RESTROOMS: The LPA observed 2 (two) restrooms in the facility, both of which are common restrooms for shared resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured and was 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. Adjacent to the kitchen is a garage. Garage remains unlocked, but contains a locked cabinet that contains cleaning supplies, personal grooming items, as well as knives and sharps. Garage also contains extra food, emergency food and water as well as storage. Report Continued on LIC 809-C 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. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. No bodies of water were observed. All exits and passageways were observed to be free of hazards. RECORD REVIEW: 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. 5 (five) resident records reviewed were complete and contained all required documents. 3 (three) staff files reviewed were complete and contained all required documents. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 11/01/2023. MEDICATION REVIEW: Medications for 2 (two) residents were observed. Both 2 (two) of 2 (two) residents' medications were observed to be maintained and administered in compliance with regulation. INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 2 (two) residents/family members. During today's visit, LPA gathered the following items: LIC 500 A copy of the facility's liability insurance No deficiencies cited. Exit interview conducted. A copy of the report was provided.