Routine inspection·April 19, 2023

Licensing Program Analysts (LPAs) Esther Cortez and KaSandra Lopez arrived at the facility unannounced to conduct a required annual visit at 9:31 a.m. When the LPAs arrived, there was three staff and all six residents present. The LPAs were greeted by staff and informed them of the reason for the visit. Administrator Christine Rowe arrived shortly thereafter. The LPAs 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: The LPAs began the inspection in the kitchen/food service area at 9:36 a.m. Knives are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 9:40 a.m., the LPAs and Administrator went to the connecting garage and observed cleaning supplies stored inside and on top of an unlocked cabinet. The garage is secured with a lock from inside the kitchen. The garage is where the washer and dryer are held, including emergency perishable food items. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The two (2) fire extinguishers were fully charged. The LPAs observed required postings throughout the common space. The backyard has a covered outdoor area equipped with furniture for client use. There are side gates for client use and is single-latched. However, administrator was advised left gate needed the spring to be tightened and the right gate needed to be fixed in order for the gate to fully self close. No bodies of water noted. Report continued on LIC 809-C. BEDROOMS: The LPAs observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six designated client rooms. RESTROOMS: The two client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway visitor restroom at 118.6 degrees Fahrenheit. MEDICATIONS: Medications review began at 10:01 a.m.; medications are centrally stored and locked in a cabinet in 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. RECORDS: Facility records were reviewed. Five client records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. All records were in order. Five personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Record review revealed one staff (Staff #1) out of three at the facility were not associated to the facility. Two (Staff #2 (S2) & Staff #3 (S3)) out of five staff files reviewed did not have proof of current first aid/CPR training. Three out of five staff files (S3, Staff #4,(S4) Staff #5 (S5)) reviewed were missing health screenings. One staff (S2) out of five had no training records available and four staff (S3, S4, S5, Staff #6) did not have proof of the 40 hours of initial training. Exit interview conducted. A copy of the report was issued.