Routine inspection·March 14, 2025

On 03/14/2025 Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the CARE Inspection tool. LPA met with Caregiver, Marilyn Nery, and the purpose of today’s visit was explained. The facility is licensed to serve four (4) non-ambulatory residents, one (1) of which may be bedridden in room two (2) with an approved hospice waiver for two (2) residents. Currently there are four (4) residents residing in the facility. Physical Plant/Structure - The facility is a single-story home in a residential neighborhood. The facility consists of three (3) bedrooms, one (1) staff room, two (2) resident bathroom, one (1) staff/visitor bathroom, living room area, dining area, kitchen with a laundry area. All walkways outside the facility were observed clean, clear, and free of obstructions, hazards, and debris. LPA did not observe any bodies of water on the premises. Bedrooms - LPA inspected all resident bedrooms and observed they had the required furniture. All rooms had bed(s), dresser, nightstand, storage space for resident’s personal belongings, chair, and ample lighting. LPA observed all beds had the required linens including mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of linens stored in resident’s rooms. Bathrooms - LPA inspected all bathrooms in the facility and observed them to be operational and within Title 22 regulations. LPA observed shower chairs and non-skid mats in the shower. The safety handrails are secured. LPA observed an ample supply of hygiene products for residents secured and inaccessible to residents. The department observed an ample supply of towels, hand towels, and wash clothes in good repair. The water temperature measured 110-degrees, 110.9-degrees and 112.6-degrees Fahrenheit. Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed all appliances were operable and in good repair. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored, packaged, and labeled. LPA observed cleaning supplies secured in a locked cabinet. LPA observed sharps and knives secured in a locked drawer in the kitchen. The water temperature measured 112.6-degree Fahrenheit. Common Areas LPA observed in the living room a large couch and four (4) chairs to accommodate all residents. LPA observed a fireplace screened and inaccessible to residents. The dining room has a large table with chairs to accommodate residents. LPA observe games and activities in resident’s rooms. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards. All rooms were observed with ample lighting. The facility was maintained at a comfortable temperature. Files LPA reviewed four (4) resident files and found they did not contain all the required documents. The department reviewed the Administrators and two (2) staff files and found they contained most of the required documents and certification. LPA did not observe training logs for 2024 or 2025. During the visit, LPA informed the Administrator licensing fees are due this month (March 2025) and provided the PIN. Medication LPA observed all Centrally Stored Medications secured in a locked closet in the hall. All medications were observed in their original packaging. LPA reviewed the medication and Medication Administration Record (MAR) for four (4) residents. LPA observed four (4) out of four (4) resident’s MARs and medication are consistent with properly documented records. Infection Control During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station and visitor log upon entry. LPA observed it has hand sanitizer, masks, gloves, and a thermometer available. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated infection control signs were posted throughout the facility. Safety LPA observed smoke detectors and carbon monoxide were operable. LPA observed a fully charged fire extinguisher with a receipt from 2024. The last emergency drill was conducted on 09/27/24. The facility has a working telephone. LPA was emailed a copy of the liability insurance. LPA inspected the First Aid Kit and found it contained the required items and a current manual. There are no firearms or ammunition stored on the premises. Deficiencies are cited on the LIC809-D page. An exit interview was conducted with Caregiver, Marilyn Nary, and a copy of this report and the Appeals Rights were provided.