Routine inspection·May 3, 2024

On 05/03/24 around 09:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required Annual Inspection. LPA was greeted by one Care Staff upon entry and explained the purpose of the visit; Nalini Bhutani, Co-Administrator (ADM) arrived about 20 minutes later. The facility’s fire clearance was approved for thirteen (13) non-ambulatory residents; hospice waivers for four (4). LPA reviewed the resident roster, staff roster, five (5) staff files, five (5) resident files and the Emergency Disaster Plan. LPA observed a visitor sign-in log at the entry. LPA and ADM toured the facility, including but not limited to bedrooms, two (2) bathrooms (BA), kitchen, common area, front yard and backyard. The facility consists of seven (7) total bedrooms. All indoor passageways were free of obstruction. There were not any bodies of water. Five (5) residents were lounging in the front yard, one (1) reading a newspaper, the others were either sleeping, watching television or engaged in electronics in the facility. A comfortable temperature for residents was maintained at 72 degrees Fahrenheit (F), and the water temperature measured at 111 (F) in BA #1. LPA observed lighting in all rooms to be adequate for the comfort and safety of all the residents. The bathrooms were safe, sanitary and in operating condition. Hand washing posters, paper towels, and soap observed at all hand washing stations. Linen and hygiene supplies were available for all residents. PPE and paper goods remain sufficient. There is a minimum supply of 2-day perishables and 7-days of non-perishable foods. continued on LIC809C... ...continued from LIC809 Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last serviced on 01/22/24, first aid kit is stored in a locked medication room, and the last emergency disaster drill was conducted on 04/01/24 with all staff; next quarterly drill to include staff and residents. The following forms are to be updated: -LIC500 Personnel Report -LIC308 Designation of Administrative Responsibility -LIC610D Emergency Disaster Plan to be updated. -An updated copy of Administrator Certificate(s) -Update personnel files Exit interview conducted and a copy of this report provided to Nalini Bhutani, Administrator.