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25 | On 9/17/2024 at 9:50am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced pre-licensing for a change of ownership. LPA met with Felinor Mariano, Administrator for Fely-Mar (Administrator Mae Morales-Altobar was not available during visit) and explained the purpose of the visit. The facility has an approved fire safety clearance for five (5) non-ambulatory residents.
While LPA was conducting a unannounced pre-licensing visit, LPA toured the facility and observed the following:
- At 10:31am knife in the desk drawer located in the living room.
- At 10:35am a knife on the kitchen counter unattended.
- At 10:37am unlocked chemicals such as, laundry detergent, bleach and other chemicals, toolbox unlocked with tools located in the garage and the door was propped open.
- At 10:44am bathroom cabinet under the sink was unlocked with chemicals such as Lysol, cleaning spray and other chemicals.
- At 10:51am drawer in cover area which had unlocked medication such as B12, multi vitamins and prescription drugs.
- At 10:57am unlocked tools in file cabinet in covered area.
- At 10:59am unlocked medication in unlocked caregiver rooms.
- At 11:00am wood planks, pole, cooking pots, ladders, curtain rods, located in the back yard
continue on LIC 809C |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
09/18/2024
Section Cited
CCR
87465(h)(2)
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7 | (h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept... persons other than employees responsible for the ...
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7 | Administrator agred to lock Caregivers doors and remove the medication in the drawers located in the covered area and submit photos to the Department by the POC date |
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14 | Based on observation, the licensee did not comply with the section cited above. LPA observed unlocked central storage for medications which poses an immediate health risk to persons in care. | 8
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Type A
09/18/2024
Section Cited
CCR87705(f)(1)
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7 | (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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7 | Administrator agreed to keep grage door closed and locked at all times. ADM also agred to keep knives locked when not inuse. DEFICIENCY CLEARED DURING VISIT |
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14 | Based on observation the licensee did not comply with the section cited above by having a knife in the drawer located in the living room and a unattended knife on the kitchen counter which poses a health and safety risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/01/2024
Section Cited
CCR
87303(a)
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7 | Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. | 1
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7 | Administrator agreed to clear the items on the side yard covered porch, purchase a lock for the storage and submit photo copies to the Department by the POC date. |
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14 | Based on observation, the licensee did not comply with the section cited above in having shed needs better lock, boxes of shoes, clutters, tools, baskets, sheets, paint bucket, and other debris located on the side yard covered porch
, which poses a potential health and safety risk to persons in care. | 8
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Type B
10/01/2024
Section Cited
CCR87412(a)
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7 | (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: | 1
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7 | Administrator agreed to have staff file available at all times. Administrator will provide the Department with a sample copy of staff files by the POC date. |
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14 | Based on record review, the licensee did not comply with the section cited above in not having files for the staff on duty which poses a potential health and safety risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/01/2024
Section Cited
CCR
87506(a)
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7 | Resident Records: The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. | 1
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7 | Administrator will ensure all items listed are complete and on file and submit a certificate of completion indicating all notated items are complete for each residents- to the Department by POC date. |
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14 | This requirement is not met as evidenced by: Licensee failed to ensure resident records were maintained. LPA observed resident files were incomplete/not on file: no consent form (CF), (ANS), emergency contact (ID), safeguards for personal property, expired medical assessments LIC 602 and appraisal needs and service plans on file for R1, R2 and R3. | 8
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