Routine inspection·April 12, 2023

On 04/12/2023, Licensing Program Analyst (LPA) David Espana conducted an unannounced annual required visit with a primary focus on CARE Inspection Tool. LPA met with Administrator Michael Gabai, Lucy Uman and explained the purpose of today’s visit. The facility is licensed to operate for six (6) residents of which six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for three (3) hospice. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's bedrooms with all six having their individual bathroom and one bathroom (7 total number of bathrooms), 1 office room, 1 living area, 1 dining area, 2 closets, 2 entrance gates observed adjacent from sidewalk, 2 six foot wood doors that give entrance to the back-side-yard were also observed, 1 kitchen, surrounding property fencing (rear and both sides of the property), 3 toilets operable/observed, 2 showers operable/observed, a total of 16 window screens were observed, 1 fireplace in the living room, 1 laundry area room in hallway and 1 outside shaded rear patio area. LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature meets the Title 22 regulations in the kitchen and bathrooms. A comfortable temperature of 73 was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Two (2) fire extinguishers were fully charged with annual maintenance of 09/24/2022 (one in the end of the hallway by exit door between bedroom 5 and master bedroom & with one in the kitchen area). 11 Smoke detectors and 1 carbon monoxide in kitchen entrance were operable. A review of 5 Medication Administration Records (MAR) was maintained in order and accurate. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. Deficiencies were cited during this inspection visit, both were Type b Technical Assistance. An exit interview was conducted, and a copy of this report was provided to Administrator Michael Gabai.