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25 | On 7/27/23 at 9:15 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Cardinal Yu-Pin Manor. Upon arrival LPA was greeted by Direct Support Administrator Wendy Hu and explained the reason for the visit. This facility is licensed to serve (49) Non- Ambulatory residents age 60 and above. The facility may retain one bedridden resident in room#11. Hospice waiver approved for five (5) residents. The last emergency disaster/fire drill was conducted on 7/2/2023. The Administrator Certificate expires on 10/10/2023 #6000702740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (7) staff files, (10) resident files, medications, and medication administration records for (10) residents.
The facility consists of a single level building with 29 resident bedrooms, each having its own bathroom. A library/activity room, chapel, laundry room, facility kitchen and dining room. The facility also has an administration office and medication room and guest restroom. There is a large patio area with sufficient seating and shaded area for resident use. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, and shower chair. In Bathroom #11, #26, and #28 skid matts/strips were missing. The temperature measured at 113.5*F-125.0*F respectively which does not meet title 22 guidelines. This poses a potential safety hazard to the clients in care. The smoke detectors were tested and observed to be working properly. The carbon monoxide detector was tested and functioning properly. There were fire extinguishers located throughout the facility, fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked. The pantry was well stocked, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the facility.
(Report continued on LIC809C.)
The outdoor grounds were toured and inspected, and the patio was well maintained with exercise a shaded seating area accessible for client use.
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Upon return LPA will conduct interviews, Training review, Finalize care tools and issue citations.
Exit interview conducted with Wendy Hu, Administrator, a copy of this report was provided. |