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25 | Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on a quarterly visits due to non-compliance concerns discussed during an office meeting on 04/23/2024. LPA Lee met with care giver Ratu Manoa Qerea who then notified administrator Julie Nonu that CCLD were present in the home. Approximately 20 minutes later administrator arrived and joined the visit. LPA Lee explained the purpose of the visit. The census is 5 with 1 facility staff.
LPA Lee and care staff Ratu Manoa toured the physical plant to ensure compliance with Title 22 regulations. LPA observed 5 resident bedrooms, 2 resident bathrooms, common area, staff room, smoking area, kitchen, laundry room, garage, and the courtyard. LPA Lee observed resident bedrooms to have necessary furniture and furnishings. Bedrooms were equipped with a bed, chair, dresser, and closet space. It was observed resident bedroom #1 had a hole that measured approximately 6 inches on the wall by the resident’s bed. Bathrooms handrails and non-skid mats are in good repair. Hot water temperature was measured at 106.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers were up to date and fully charge. No emergency exits were obstructed. LPA reviewed food supply to ensure that the facility had a 2-day perishable and 7-day nonperishable food supply and it were sufficient. LPA Lee observed the pantry locked and made inaccessible to residents. Per administrator, the pantry is locked at night due to a resident who is diabetic and likes to eat sweets. LPA Lee observed the laundry room where it was observed that detergent, and all cleaning supplies were locked and made inaccessible to residents at this time. Knives were observed to be locked and made inaccessible. First aid kit was checked and it is complete.
LPA requested to review 3 resident files and 2 staff files. Staff files and resident files were observed to be current with up-to-date. LPA Lee reviewed 3 resident medications and it was up to accurate and complete.
As a result of this visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
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