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25 | 03/11/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 8 residents in care. Facility approved/cleared for 10 non-ambulatory which 10 may be bedridden and approved hospice waiver for 4. LPA was greeted by staff. Administrator, Dharmi Patel arrived shortly after.
At approximately 10:00 am, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.
All rooms were furnished per regulation. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 110.4 and 108.9 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 03/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility conducts quarterly fire and disaster drills with the last one being conducted 01/15/2025. Sharps that could pose threat if available to residents were located in a kitchen drawer and were found to be secured. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.
LPA conducted a review of 5 resident records. All records had the required documentation. LPA conducted review of 5 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.
No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/12/2025:
LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610E: Emergency Disaster Plan
Updated Liability Insurance
Exit interview conducted with Administrator and a copy of this report was provided. |