Follow-up on corrections·January 23, 2023

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management Visit in conjunction with an initial complaint visit (Complaint Control Number: 20230118161528). LPA met with the administrator, Victoria Torres, and explained the reason for the visit. During a physical plant tour, LPA discovered conflicting facility layouts that do not conform with the Department’s approved facility sketch. The first conflict was discovered in the room labeled “Staff Room” which was approved as one room with a window and closet, however, facility built an unapproved floor-to-ceiling wall which runs down the middle of the room and the only window (wall runs the length of the room and each side of the room shares a portion of one window). The room also has an unapproved interior door to gain access to the right side of the Staff Room (essentially, a room within a room). The other conflict was discovered in the room labeled “Room #5” (five). This room also has an unapproved wall that runs the length of the room, but unlike the Staff Room, it has individual entry doors and a full window in each room. The facility labeled the doors #5 and #6. Furthermore, in Room #4 (four), LPA discovered electrical wires running from the outlet through the bedroom wall into the closet, then runs along the floor, from one side of the closet door to the other, then through the interior of the closet wall, and out through the bedroom wall to power a wall mounted television. These wires pose a potential tripping hazard. LPA also discovered that the carbon monoxide detector in the dining/kitchen area is not operational. Smoke detectors in the hallways are old and also not operational. Under Title 22 regulations, the following citations are issued and recorded on LIC 809-D. Exit interview conducted and a copy of the report was issued.