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25 | Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with House Manager, Jade Robles and explained the purpose for the visit. Licensee/Administrator, Paul Shay, arrived shortly after to assist with the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Jade, observed the facility food supplies, reviewed (4) resident medications, (4) resident files, (3) staff files, and conducted interviews with (2) staff and attempted with (4) residents. The facility is a single-story home, operating as an Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents, of which (1) may be bedridden. It has a hospice waiver approved for (6). Currently, there are (3) residents on hospice.
All resident bedrooms were inspected and had the required furniture, storage space, and lighting. Bathrooms were equipped with a toilet, wash basin, and showers. They were observed to have the required grab bars and non-skid mats. The hot water was tested and measured at 114*F, which is in compliance. The food supplies was observed and had the required 2-day perishables and 7-day non-perishables, as well as emergency food and water supplies available. Fire extinguishers were observed throughout the premises, with current inspections and were fully charged. Walkways and ramps were observed to be free of debris and obstructions/hazards. Auditory devices were observed and operable at all entrances/exits of the facility. Sharps, cleaning supplies, and centrally stored medications were observed stored and inaccessible to residents in care. Laundry equipment was observed in good repair and operational during the visit. Sufficient linens, towels, and personal hygiene supplies were available. The facility has an approved mitigation plan on file and a current infection control plan submitted to the department. Sufficient PPE supplies were observed. Smoke/carbon monoxide detectors were observed in each room. Last fire drill was conducted on 10/15/23. Staff and resident files were reviewed for required documentation, and observed to be complete. Resident's medications were reviewed and observed to be documented properly and given as prescribed.
During today's visit, no deficiencies were observed or cited.
An exit interview conducted with Administrator. A copy of the report was provided. |