Post-licensing visit·September 7, 2023

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced post-licensing visit to this facility at 08:55AM. LPA met with backup Administrator Harold de Guzman. Administrator was contacted via telephone and arrived at 09:52AM. Entrance interview conducted. Beginning at 10:00AM, the 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: Hardwired combination smoke and carbon monoxide detectors were tested at 12:39PM and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and purchased 06/24/2023. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 3 (three) total bedrooms, all of which are designated for shared resident use, but are currently single occupancy. RESTROOMS: The LPA observed 2 (two) restrooms in the facility; one is a shared restroom and one is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in both resident restrooms and measured within the required range. 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 side yard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage was observed locked and contained the laundry area, locked cleaning supplies, emergency food, and storage. Report Continued on LIC 809-C KITCHEN : Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and other sharps were observed locked in a kitchen drawer. Cleaning supplies were observed in a locked under-sink cabinet. RECORD REVIEW: Began at 10:30AM, 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. 2 (two) resident records reviewed were complete and contained all required documents. 2 (two) staff files were reviewed; both 2 staff files contained all required documents. MEDICATION REVIEW: Began at 11:40AM. Medications for 2 (two) residents were observed. Physician's Reports indicate both Resident #1 (R1) and Resident #2 (R2) are able to store and administer their own medications. As thus, the facility centrally stores R1 and R2's medications and the residents prepare their own pill boxes for daily administration. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control practices. 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. Emergency disaster drills will be conducted quarterly. INTERVIEWS: Throughout today's visit, LPA interviewed 2 (two) staff and 1 (one) resident. No citations issued. Exit interview conducted. A copy of the report was provided.