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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual and met with Alex Timis, Administrator, and explained purpose of the inspection. Also present was staff, Rebeca Timis. LPA observed (2) residents watching television in the common area, (3) residents in their rooms and was advised (1) resident was currently attending activities at their health care plan provider. The facility is licensed for (6) residents - (5) can be bedridden and (1) must be ambulatory. Residents are appropriately placed based on the fire clearance. Currently there are (2) residents on hospice- facility is approved for (4).
LPA and Administrators toured the interior/exterior of the facility including the common areas, resident bedrooms (6), resident bathrooms (3.5), kitchen, staff rooms, laundry and medication/office area. All resident rooms are private and (5) have a sliding exit glass door with an auditory alert when opened. LPA observed the facility to be clean, in good repair and to have sufficient furniture/lighting. Resident bathrooms (3) have a walk-in shower with grab bars, non-skid flooring, paper towels, trash cans with a lid and hand-washing posters (60 seconds). There is sufficient 2+day perishable food, including fresh produce, and 7+day non-perishable supply of food. Sharps and medications are locked in/near the kitchen and toxins are locked in the laundry area. The inside temperature was 73*F and hot water measured 108*F in the kitchen. The hot water heater is set at 110*F. Fire extinguisher last serviced 1/28/25, and the smoke/monoxide alarms are working. The last quarterly fire drill was conducted on 1/2/25- facility will complete a variety of emergency drills and at different times of the day. There are sufficient PPE supplies, linens, blankets, and towels. There is sufficient indoor/outdoor space. RCFE Administrator certificate #7001261740- exp 11/4/25. A second staff has Admin cert # 6071889740- exp 7/15/26. Shower/medication schedules, and activity/menu are posted.
LPA reviewed (2) resident files and (3) staff files- files were found to be organized and contain current/required documentation. Medications were reviewed for (1) resident- orders match medications on hand and documentation is current. Staff have completed all required annual training and additional training in January 2025. Admin to email updated copy of LIC308/LIC500. All required postings were observed. LPA observed an updated Dementia Care Plan to reflect the updated regulations, effective 1/1/25.
There were no deficiencies observed. Exit interview. Copy of report provided to Administrator. |