Routine inspection·October 30, 2023

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Jovy Sarreal arrived shortly thereafter. The LPA and 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: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed one (1) designated drawer in the kitchen where knives and sharps are locked and inaccessible to residents. Medications were observed locked in a cabinet adjacent to the kitchen. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed one (1) designated drawer in the kitchen where knives are locked and inaccessible to residents. Medications were observed locked in a cabinet adjacent to the kitchen.BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There was a linen closet in the hallway with extra towels and linens. RESTROOMS: Restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. Three (3) common restrooms and one (1) private restroom’ water hot water was measured and were in compliance measuring between 105- and 120-degrees Fahrenheit. Two (2) out of the four restrooms were being remodeled at the time of the visit. The administrator stated that the CCL office was informed of the renovations/construction being done on 10/27/2023. Continued on LIC 809C… COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was fully charged and were last serviced on 06/12/2023. The LPA observed required postings throughout the common space. The washer and dryer are adjacent to the kitchen area. All laundry materials are located in a locked cabinet and inaccessible to residents. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. The garage is attached to the house and has a door by the front yard. The garage door was locked at the time of the inspection. RECORDS: Records review began at 1:00 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:45 p.m.; medications are centrally stored and locked in a cabinet adjacent to the kitchen. 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. INFECTION CONTROL : The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Fire drill - Liability Insurance No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.