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25 | Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 4/9/2022 at 10:15am to conduct a Post Licensing visit. LPA was met by Henrietta Acevedo, LVN Health & Wellness Director and Sandra Ealy, Sales & Marketing Director and stated the purpose of the visit. Joy Carter, Administrator was also contacted and arrived within 1 hour to assist with todays visit. The administrator certificate for Joy Carter expires 12/11/2022. The facility is licensed to serve 83 non-ambulatory residents of which 22 maybe bedridden,. There are 9 residents receiving hospice care services at this time. LPA and Henrietta Acevedo, LVN Health & Wellness Director and Sandra Ealy, Sales & Marketing Director toured physical plant inside and outside to ensure safety for the residents, and all passageways are clear and free of hazards. The team toured a random amount of rooms 107,108, 142,146, 151,154, 201, 214, 221, 224, 228. LPA observed the elevator permit expires 4/30/22, the fireplace(s) have screens, staff are wearing masks for covid-19 properly, covid precautionary measure signs are posted, trash cans are covered, there are 3 evacuation chairs in the stairwells.
The temperature inside the facility was measured at 74*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 107.8*F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations.
LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, pull alarm system, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA spoke with medication staff who explained the medication procedure as well as the destruction process.
LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises.
The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.
Based on a file review there were no annual documents that need to be updated and submitted at this time. At 11:30am LPA observed 2 staff and 2 resident files that were made available for review during this visit.
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited. Exit interview held, copy of report given. |