Routine inspection·February 23, 2024

Licensing Program Analysts (LPAs) Mariana Agban and Perchui Khurshudyan conducted an Annual Required visit and inspection of the facility. LPAs met with staff and explained the reason of the visit. At approximately 10:45 am, with the assistance of staff, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms were tested and function properly. The carbon monoxide detector was tested and functions properly.The fire extinguisher is located in the hallway. The purchase date Jan 3,2023. Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were four (4) bedrooms designated for residents' use. Three (3) designated for residents' use and one (1) for staff. All three bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are one (1) bathroom designated for residents' use. The bathroom was properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 105.3 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas : These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit . Surrounding Grounds : Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area is located in the garage, which is inaccessible to residents. Resident Files : LPAs conducted a file review of resident records to insure compliance of licensing forms. Staff Files : LPAs also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications : Medication and Medication Records were reviewed. LPAs observed LEVOTHYROXINE medication is short by 1 bill for 2 out 2 residents. Assistant administrator couldn't explain the reason for the shortage. They were advised to use Medication Administration Record (MAR) to prevent any future issues with medications. Exit Interview conducted, citation issued and a Copy of the Report delivered