Facility Evaluation Report

Licensing Program Analysts (LPAs) Celine De Perio and Albert Marin conducted an unannounced required annual inspection in this facility. Administrator Theresa Kholoma and House Manager (HM) Rudy Ignacio were informed about the presence of LPAs in the facility. HM Ignacio arrived in the facility. LPAs stated the purpose of the visit.

The facility is licensed for capacity of six non-ambulatory of which 1 may be bedridden; and with hospice waiver for six. For this visit, there were three residents under hospice care.

At 11:03 AM, LPAs De Perio and LPA Marin were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure of the facility. LPAs observed five residents in care, while the sixth resident was out with a family member. LPAs observed two staff members on the floor. LPAs toured the interior and exterior portions of the facility with the House Manger, Rudy Ignacio. There were two private and two shared resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide and auditory exit alarms were observed to be operational. Fire extinguisher was mounted and charged. Bathrooms were provided with grab bars, and hot water temperature was measured at 120 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. LPAs observed that knives and sharp kitchen tools were in a drawer that was not locked. LPAs observed disinfectant solutions and toxins located in a garage, however LPAs observed that garage door was unlocked and open.

At about 11:15 AM, LPAs observed 33 bottles of medication in Resident #1’s (R1) bedroom in plastic boxes, opened, sealed, with some expired medication. Per file review, R1 is unable to store own medication per physician report issued on March 24, 2021.