Routine inspection·April 17, 2024

Licensing Program Analyst (LPA) Darius Williams conducted an unannounced annual inspection visit. LPA Williams met with Staff Marilou Bernardo Pending Administrator, Adam and discussed the purpose of the visits. Four residents were present. LPA Williams toured the facility with Staff. Facility tour began in the front yard. The yard and pathways were clean and free of obstruction. Upon, entrance to the facility, LPA Williams observed required facility postings on the wall. The kitchen was clean and in good repair. Knives and sharps were observed locked and inaccessible to residents.. There were 2 days of perishable and 7 days of non-perishable food supplies. Dining room and living room was clean and had seating available for all residents. Facility temperature reflected 75 degrees Fahrenheit. LPA observed 4 bedrooms. Bedrooms had space for clients and were clean and in good repair. Rooms had mattress, linens, dresser, night stand, and working lights. Room were personalized by clients. Two bathroom for client use, was clean and in good repair. Shower, sink, and toilet all had running water. Tour finished in the backyard. There was seating and shaded area available for client use. Medications and chemicals were observed locked and inaccessible to clients. *Continued on LIC 809C* Smoke detectors, carbon monoxide, and fire extinguishers were present and operational. First aid kit was present and had all required items. LPA reviewed 3 files and 3 employee files. All files employee files had all required documents requested by the LPA. 1 of 4 resident files did not have record of their Tuberculosis screening. Additionally, the LPA did not locate a Pre-Admission appraisal in 4 of 4 resident files. Deficiencies are being cited on the attached LIC 809D page. Plan of correction was reviewed and discussed. An exit interview was conducted and a copy of this report and appeal rights was provided.