Routine inspection·May 5, 2025

LPA Tuesday Cabiness conducted a required annual inspection at the facility. Upon arrival, LPA met with caregiver Mario Ilagan, who was informed of the purpose of the visit. LPA was granted entry and observed two additional staff members on duty. Caregiver Mario contacted Administrator Allen Rapisura, who arrived shortly thereafter and was also informed of the visit's purpose. The current census is five (5) residents. The following required licensing documents were visibly posted: facility license, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, and neighborhood complaint procedures. Physical Plant Tour: A comprehensive tour of the interior and exterior of the facility was conducted. The following areas were inspected: Kitchen/Food Supply: The food service area met Licensing requirements: a seven (7)-day supply of nonperishable food and a two (2)-day supply of perishable food. Food was wrapped and stored properly. Food preparation and storage areas were clean and pest-free. Kitchen appliances were clean and in working condition. The kitchen had been remodeled with freshly painted cabinets and new counter tops. Walls and floors were clean. Chemicals, household supplies, knives, and medications were locked and secured in the kitchen, garage, and closet. Living/Dining/Family/Staff Areas: All indoor passageways were clear of obstructions. Rooms were clean, adequately furnished, and comfortable for residents. Bedrooms: The facility contains seven (7) bedrooms and two (2) bathrooms. Six (6) residents occupy the facility; one (1) bedroom is designated for staff use. During the previous inspection on 07/09/2024, LPA observed a newly constructed room in the garage area for staff use. The facility later removed the construction and submitted photos to LPA. Since the additional room was not approved by Licensing and did not match the original facility sketch, Administrator Allen initiated the process to obtain proper approval and fire clearances to modify the license for five (5) non-ambulatory bedrooms and one (1) staff bedroom. The room lacked prior approval from the city and fire department. However, since the last annual visit, the Administrator has remained in regular communication with both departments regarding code compliance and licensing updates. During this visit, LPA received emails from the Administrator demonstrating what is needed to obtain final approvals. Once all approvals are secured, the Administrator will submit an updated LIC 200 and new facility sketch to reflect the structural changes and fire clearance. Bathrooms: Bathrooms were clean and functioning properly. Grab bars were appropriately installed in toilets and showers. Hot water temperature was within regulation. Surrounding Grounds: Smoke alarms and carbon monoxide detectors were tested and found to be operational. The fire extinguisher was fully charged. No visible hazards were observed; indoor and outdoor passageways were unobstructed. The backyard featured a covered patio with appropriate seating for residents. The swimming pool was securely fenced and locked at the time of the visit. Record Review: Resident Records : Resident #1 (R1 & R2) had missing documentation due to staff misplacement. Staff Records : No discrepancies were observed. Medications : Medication storage and records were reviewed. But, the facility has accepted (2) additional hospice residents, when there waiver is only approved for (2). An exit interview, citations, appeal rights, and a copy of the report was given to the Administrator.