Routine inspection·August 27, 2024

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there were two (2) staff and four (4) residents present. LPA met with the Administrator, Maria Calles and explained the reason for the visit. Entrance interview conducted. The LPA 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: KITCHEN: The LPA inspected the kitchen/food service area at 8:57 a.m. Knives and sharps were observed locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 113.5 degrees Fahrenheit at 9:00 a.m. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. Smoke and carbon monoxide detectors were tested, and all were functional at the time of the visit. Fire extinguisher was observed and fully charged on 05/17/2024. No fire clearance concerns were observed. The LPA observed required postings throughout the common space. Activities were observed in the common areas. There is a working telephone on premises. RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. Report Continued on LIC 809C... Report Continued from LIC 809... The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 8:49 a.m., the water temperature was measured in both bathrooms, and they measured between 105.3- and 113.5-degrees Fahrenheit. BEDROOMS: There are six (6) total bedrooms in the facility; one (1) is designated as a shared room; four (4) are designated as private resident rooms; and one (1) is a staff room. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. LPA observed a closet with additional clean linens, blankets, and towels for resident use. There is a locked closet with resident’s personal hygiene items inaccessible to residents in care. GARAGE/BACKYARD: The garage was inaccessible to residents at the time of the visit. Washer and dryer were observed inside the garage. Laundry detergent was observed locked and inaccessible. LPA observed an adequate amount of emergency food and water. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear of obstructions. LPA observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit. RECORDS: LPA reviewed Resident Records at 9:11 a.m. and Personnel Records at 9:59 a.m. Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Three (3) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff files were complete. The Administrator’s certificate is active and expires on 10/21/2024. Report Continued on LIC 809C... Report Continued from LIC 809C... INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 07/25/2024. MEDICATIONS: Medications review began at approximately 11:25 a.m. for four (4) residents. Medications are locked in a filing cabinet in the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit. Exit interview conducted. A copy of the report was provided.