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25 | On this day Licensing Program Analysts (LPAs) Michael Tea and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 98 residents, of which 50 may be non-ambulatory. Facility has an approved hospice waiver for 3 residents and the facility currently has 85 residents. Administrator (AD) Rosario Nazareno and Licensee (LE) Brian Nazareno arrived shortly to conduct facility tour. AD Nazareno has a valid certificate that expires on 9/9/2025. AD provided updated liability insurance that expires on 3/19/2025.
LPAs along with LE Nazareno toured the facility at 8:40 AM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 100.9 degrees F and 112 degrees F in all restrooms. Common areas were clean and clear of hazards. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detector system was tested by the fire authority on 11/14/2024. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 9/28/2024. Outside grounds were toured. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise, arts & crafts, and bingo. There is shaded outdoor seating for residents. LPAs observed the emergency food and water supply. LPAs reviewed 8 resident files and 8 staff files. Reviewed resident files contained required documentation including admission agreements, physician reports, resident appraisals, LPAs interviewed 4 residents and 4 staff. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training.
CONTINUED ON LIC 809C DATED 1/7/2025 |