Post-licensing visit·December 11, 2024

On 12/11/2024 at 1:00PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced post licensing inspection. LPA met with Barbara McMillion, Caregiver. Barbara contacted Administrator, Tarra Abdullah-Grayson via telephone and advised purpose of visit. Administrator, Tarra Abdullah-Grayson gave authorization to Barbara McMillion to sign the reports. LPA toured facility including but not limited to bedrooms, bathrooms, dining area, living room, kitchen, garage, and outdoor area. Fire extinguisher was observed to be full and last purchased on 05/23/2024. Medications were in a locked cabinet in the kitchen. Comfortable room temperature is maintained at 74 degrees F. Hot water temperature in the shared residents’ bathroom was measured at 111.1 degrees Fahrenheit. One week of non-perishable and 2-day perishable food supplies were sufficient. Carbon monoxide and smoke detectors were observed in operating condition. First-aid kit was complete, and hygiene items for resident general use are sufficient. Extra linens and towels were observed in the hallway closet. Last fire drill was conducted on 11/20/2024. There are no accessible bodies of water observed. LPA reviewed one (1) out of one (1) resident’s record and three (3) staff records starting at around 1:15PM. All staff are fingerprint cleared and associated to the facility. The resident in care has a physician's report, needs & service plan, and admission agreement on file. LPA also reviewed one (1) resident’s medication and medication logs. All PRN medications have physician's orders. LPA attempted to interview resident however, wasn't successful as the resident has dementia and is non verbal. Continue on LIC809C. Continued from LIC809 No deficiencies cited during visit. The following forms to be updated and submitted to CCL by 12/18/2024: · LIC 500- Personnel Report · LIC 308- Designation of Facility Responsibility · LIC 610E- Emergency/Disaster Plan (9 pages) · Evidence of Liability Insurance Exit interview conducted and a copy of this report provided to Barbara McMillion.