Routine inspection·November 21, 2024

On 11/21/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Direct Support Professional, Vanndy Nhey, explained reason for visit and was permitted entry into the facility. Administrator, Itaska Mask was contacted and arrived a short time later. LPA completed tour of the facility inside and out. Residents not present at time of visit. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 03/19/2024. Last fire drill on 11/12/2024. Water temperature measured 112.4 degrees F in resident bathroom #2. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. LPA observed sufficient seating under covered patio areas. The following issues were observed during time of visit: Staff restroom missing hand washing sign. Chemicals observed in staff restroom unlocked and accessible. Scissors observed on counter top of medical station. 4 of 4 residents bedrooms observed without box springs. Kitchen drawer with sharps observed unlocked and accessible. Chemical/items posing a hazard to residents in care observed in hallway closet unlocked and accessible. Bedroom #3 exit door broken and in need of repair to bottom of door. Touch up paint needed around thermostat. Right side gate latch in need of repair/replacement (gate does not latch). Concrete lifted at back corner of house (potential tripping hazard). Fence boards on right and left side of facility in need of fixing/replacement. Debris on left side walkway in need of removal. CONT... CONT... LPA requested the following documents to be submitted to CCL by 12/02/2024: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020), copy of liability insurance in order to update the facility file. Exit interview completed with Administrator, Itaska Mask. A copy of this report, deficiency, TV's and appeal rights provided.