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25 | Licensing Program Analyst (LPA)Sabrina Calzada arrived unannounced to conduct a required annual and met with Titus Popa, Administrator, and explained purpose of inspection. Also present was caregivers, Valerie Popa and Ted Popa. LPA observed (3) resident in the common area and (2) residents in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (4). Currently, there are (2) residents on hospice.
LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms (1) shared resident bedroom, (2) resident bathrooms, kitchen, office, staff rooms and laundry/garage area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps in the kitchen. LPA observed locked medications in a separate cabinet near the kitchen and locked toxins in the laundry room. LPA observed the inside temperature to be 76*F and hot water measured 105*F in a resident bathroom. LPA observed games/activities on site. The fire extinguisher was last serviced on 1/5/2024. There are sufficient towels, linens, paper products and PPE. First Aid kit is complete. There is a walking track in the front patio area and covered patio with seating on the back patio. There are (2) unlocked exit gates.
(3) resident files were reviewed and found to be organized and contain current documentation, including care plans/physician's reports. Medications were reviewed for (2) residents- orders matched medications being administered and documentation is complete. (5) staff files were reviewed and found to be complete, organized and contain current training documentation, including First Aid/CPR. RCFE Administrator certificates are current. All staff are cleared and associated to the facility. Infection Control Plan was reviewed/approved. Emergency Disaster Plan was reviewed and is posted. Administrator to ensure current list of personal rights is posted and included in admission agreement. Obtained copy of current liability insurance and LIC308. LIC500 to be provided by 3/13/24.
There were no deficiencies observed. Exit interview. Copy of report provided. |