Routine inspection·December 23, 2024

On 12/23/24 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Staff, Raijanae Harris, introduced self, explained reason for visit and was permitted entry into the facility. Administrator, Itaska Mask was contacted and arrived a short time later. LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. 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. Some run on a fire system. Fire extinguisher last serviced 03/19/2024. Last fire drill was on 11/20/2024. 2 of 4 resident rooms observed to have the required furnishings. All observed with adequate lighting. Linen supplies are kept in linen closets. Sharps and chemicals were located in locked closets/cabinets. LPA observed sufficient seating under covered patio areas. The following issues were observed during todays visit: Water temperature measured 94.1 degrees F in bathroom #3. 2 of 4 resident bedroom observed with out chairs. R1 bedroom observed with paint in need of touch up. Medications observed in refrigerator unlocked and accessible. Sample linen observed torn and in need of replacement. Bathroom #2 cabinet under sink in need of repair. Bathroom #3 cabinet door under sink in need of repair. Bathroom #3 observed in need of cleaning in shower area. Gate wire on right side gate in need of repair. Debris along right side fence, back yard fence and in garage in need of removal. Right side of patio observed with moss on concrete in need of cleaning. Holes from neighbors dog in need of filling along right side fence. Wall near dryer vent on left side of yard in need of cleaning. Gate on left side of yard not self-latching. Fence board on left side of yard observed with rot in need of replacement. Spider webs observed in garage in need of cleaning. Meeting point missing on facility sketch. CONT... CONT... LPA requested the following documents to be submitted to CCL by 1/3/24: 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) in order to update the facility file. Exit interview completed with Administrator, Itaska. A copy of this report, deficiencies, TV's and appeal rights were provided.