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25 | At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Jessica Lopez. Administrator, Angelica Martinez, arrived to facility at approximately 10:15AM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance for 5 non-ambulatory residents and 1 ambulatory resident for a total capacity of 6 residents. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 5 Residents in care and 2 staff members on-site.
At approximately 9:40AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:20AM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 2 story building with 6 Resident bedrooms, 3 resident bathrooms, one shower room, 2 staff rooms, 1 staff bathroom, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. During walkthrough, LPA observed that facility currently does not have an evacuation chair on-site, but all residents currently live on the first floor (See Technical Advisory, LIC9102, H&S Code, 1569.695(f)(1)). LPA advised Administrator to purchase an evacuation chair in the event they have a resident move into the room located on the second floor.
LPA reviewed staff files, resident files and resident medications. All Files were all found to be well organized and thorough. During staff file review, LPA observed that 3 of 5 staff files did not have an LIC501/Personnel Report (See Technical Advisory, LIC9102, regulation 87412(a)(7)). Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure.
Continued on LIC809C |