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32 | LPA observed some of the emergency disaster supplies including food/water in the office/medication room. However, the generator, portable radios, and etc. were not maintained by the facility as indicated on the Emergency Disaster Plan (LIC610E). Emergency evacuation drills are being conducted quarterly. The first aid kit contains all necessary elements. The first aid manual was not current which was published in 2006. The facility land line number, 949-859-5113, was tested and remains available. The liability insurance is also current. LPA observed the required 'See Something, Say Something' poster (PUB475) framed in an incorrect size in the living room. The Administrator's Certificate for Luis Gaitan expires on May 6, 2025.
LPA conducted an audit of three residents' files and one personnel files. Discrepancies were noted in one staff file as the Tuberculosis (TB) test results were not present. Medications were audited for three residents. No discrepancies noted. Staff and resident interviews were conducted.
The following items were noted and discussed with Admin Lisa Gaitan and HM Jimenez: to enlarge the complaint poster in the correct size and to post it in the entry way, to obtain a current first aid manual, generator, portable radios, and etc, to repair one auditory device, screen, and sliding door handle in one resident's room, clean out pantry and the food crumbs on the canned food, and to label the expiration dates, and to obtain the TB Test results for one staff. Admin was also reminded to ensure timely payment of the annual licensing fee due January 20, 2025.
Based on the observations made during today's visit, deficiencies are being cited today. Advisory Notes are also being issued.
An exit interview was conducted with Administrator Lisa Gaitan and House Manager Concepcion Jimenez, and a copy of this report and the LIC809-D, and LIC9102s were provided at the end of the visit.
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