Routine inspection·November 30, 2023

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced annual inspection. LPA was greeted by staff and the LPA explained the reason for the visit. The LPA communicated with the Administrator Cilva Toume and explained the reason for the visit. The Administrator stated that she would arrive within 20 minutes to the facility. At 11:30 a.m., 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. COMMON AREAS: At 11: 40 a.m. the living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is not in operation and is blocked by the television cabinet and the television. The facility is maintained a comfortable temperature of 76 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 was last purchased on 06/13/2023. The LPA observed required postings by the entrance of the facility. BEDROOMS: At 11:45 a.m. it was observed that the facility has six private residents’ bedrooms and two staff bedrooms. Every residents’ room has a direct exit to the yard. The LPA and Administrator observed that in bedroom #1, the door that leads to the bedroom’s private patio area was open. This patio has a gate that leads to the front of the house, and access to the street. The gate has a latch; however, the gate does not have a signal system to alert the staff if the resident opens the gate. The private patio area was observed to have old furniture (two mattresses), a tank of propane gas, which the administrator stated that it was empty, and two folding chairs. During the inspection, staff removed all the items from the private patio. Additionally, the rooms’ closet was observed to have a mattress inside leaning against the closet’s wall. At the time of the visit, bedroom #2 and bedroom #3 sound systems were not operational, however during the visit the administrator put in the new batteries. Signal system was tested and was operational when LPA checked bedroom #2. Staff was working on signal system for bedroom # 3. Bedrooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: Facility has one common bathroom and private bathrooms in room#1 and #5. Bathroom s are equipped with grab bars and non-skid mats in the shower area for residents' use. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperatures measured as follows: Bathroom in bedroom #1 at 127.4 degrees Fahrenheit, bathroom in bedroom #5 at 124.6 degrees Fahrenheit. KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 126.6 degrees Fahrenheit. OUTDOOR AREA/GARAGE: The backyard has an outdoor area equipped with furniture for client use. The shade/canopy is worn out and torn. Shade needs to be provided for residents. There is a side gate for client use and is single-latched. No bodies of water noted. The emergency passageway had three bicycles standing in the passageway; the administrator moved the bicycles out of the way during the inspection. Three (3) paint cans, and two (2) bottles of bug pesticide were observed to be accessible to residents in an open metal cabinet located in the right-hand side passageway outdoor area. A bag of construction material, which was clearly labeled as ‘Danger: Causes severe skinburns’… was observed to be open and accessible to residents in an unlocked wood cabinet located in the right-hand side passageway outdoor area. All dangerous materials were removed during the inspection. The garage is attached to the home. The door was locked at the time of the inspection. The washer and dryer are located inside the garage. Cleaning supplies were located inside the garage. RECORDS: Records review began at 1:10 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. At 1:50 p.m. 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. Residents and staff record are kept in a locked kitchen cabinet. MEDICATIONS: Medications review began at 2:15 p.m. Medications are centrally stored and locked in a cabinet in the kitchen area; 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 Deficiencies were cited at this time. Exit interview conducted. A copy of the report, and Appeal Rights were issued.