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Inspection visit

Routine inspection (multi-day)

WESTCHESTER HOME ON SPRUCE, THELicense 1572091918 citations on this visit
8 citations recorded

Inspector’s narrative

What the inspector wrote

On 4/08/25, Licensing Program Analyst (LPA) M. Medina and Licensing Program Manager (LPM) A. Walton conducted an unannounced Annual Continuation visit to facility. LPM and LPA arrived, introduced self, stated purpose of visit, and allowed entrance by Caregiver. Designee, Rosanda Anderson, contacted by telephone and arrived a short time later to conduct facility visit. During last facility visit, Administrator on record was not present and LPA was informed that she had been absent from facility and had moved out of state to attend school. Prior to today's inspection, LPM Walton received a Administrator packet for Rosanda Anderson that is currently under review. Resident bedrooms toured, residents rooms are observed to have required furnishings, Resident bathroom toured, water temperature measured at 119 degrees F. Shower/Tub observed to have a non-skid mat and shower chair available. Kitchen observed to have a locked wrought iron gate making kitchen inaccessible to residents. The wrought iron gate was not in place, when facility received fire clearance. LPA observed facility has a 7-day supply of non-perishable food available or a 2-day supply of perishable food available. Medication reviewed and observed that 3 out of 5 residents did not receive medications due to medication being refilled. R1 has medication listed on physician's report, care plan, and hospital discharge paperwork, R1's medication is not on hand or listed on MARS or Centrally Stored Medication. Facility is unable to provide documentation for discontinuation of R1's medication. Staff and resident files reviewed. All staff files reviewed are missing proper documentation for training. Resident files were incomplete and did not contain Appraisal/Needs and Services Plans. Outside of facility toured. LPA observed shaded area with table but no adequate seating available. LPA observed several chairs in the backyard that need removal and/or replacement. Designated fire exit in back yard exiting to street was locked at time of inspection. As LPA and LPM were leaving facility on 4/08/2025, they observed the interior of front door of facility to have a pin pad that required a code to open front door to exit and a door security guard on the lower left corner to of door. There is a door latch on french doors leading to back patio that need to be removed. All deficiencies observed are being cited on the attached 809-D. Immediate Civil Penalty Assessed. Exit interview conducted. A copy of report provided to staff for facility records.

Citations

8 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.618(b)Type B

    Based on interview and record review, the licensee did not comply with the section cited above. During last facility visit on 3/28/25, Administrator on record was not present and LPA was informed that she had been absent from facility and had moved out of state to attend school. which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 1569.618(c)Type B

    Based on record review, the licensee did not comply with the section cited above care plans on file for all residents state residents should have 1:1 staffing, which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 1569.625(c)Type B

    Based on record review, the licensee did not comply with the section cited above all staff files reviewed did not contained training regulations as mandated, which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87202(a)Type A

    Maintain fire clearance before retaining specified persons

    Based on observation, the licensee did not comply with the section cited above kitchen observed to have a locked wrought iron gate making kitchen inaccessible to residents. The wrought iron gate was not in place, when facility received fire clearance. Designated fire exit from backyard observed to be locked at time of inspection, which poses an immediate health, safety or personal rights risk to persons in care.

  • 87208(a)Type B

    Maintain and operate facility under definitive plan

    Based on record review, the licensee did not comply with the section cited above facility is not following plan of operation, which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87465(a)(1)Type B

    Arrange appropriate medical and dental care

    Based on interview and record review, the licensee did not comply with the section cited above R1 should be receiving Physical therapy and has not attended scheduled appointments since initial examination, which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87465(a)(6)Type A

    Maintain records of centrally stored medication dosages

    Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 residents Medication reviewed and observed that 3 out of 5 residents did not receive medications due to medication not being refilled, which poses an immediate health, safety or personal rights risk to persons in care.

  • 87506(b)Type B

    Resident record must include minimum required items

    Based on record review, the licensee did not comply with the section cited above in 5 out of 5 resident files are missing doucments which poses/posed a potential health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the April 8, 2025 inspection of WESTCHESTER HOME ON SPRUCE, THE?

This was an other inspection of WESTCHESTER HOME ON SPRUCE, THE on April 8, 2025. 8 citations were issued: 2 Type A (serious) and 6 Type B.

Were any citations issued to WESTCHESTER HOME ON SPRUCE, THE on April 8, 2025?

Yes, 8 citations were issued (2 Type A, 6 Type B). The first citation was for: "Based on interview and record review, the licensee did not comply with the section cited above. During last facility vi..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.