Routine inspection·March 17, 2022

Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at 1:35pm on 03/17/2022 to conduct a One (1) year Required Infection Control visit. LPA meet with Anna Vardanyan and explained the purpose of this visit. The facility has an approved mitigation plan on file. A tour of the physical plant was conducted at 1:40pm and the following was observed: The facility has three (3) bedrooms and two (2) bathrooms currently occupying five (5) residents. The facility has one main entrance being used, there are required Covid-19 prevention signage (handwashing, coughing etiquette, and physical distancing) posted. The PPE screening station is located on the front porch on a table near the entrance equipped with sufficient PPE readily accessible, a standing free hand thermometer, hand sanitizer, gloves, mask, and sign in sheet at the time of visit, also a PPE screening station inside the facility at the entrance equipped with PPE essentials. The facility maintains a comfortable temperature at 70-degree Fahrenheit. The facility has a fire clearance for four (4) non-ambulatory and one (1) bedridden with a hospice waiver for (2). The facility has auditory alrams on all exits. Kitchen: At 1:43pm the kitchen was observed to be clean and an adequate supply of perishables and non-perishable food located in the refrigerator, freezer, and kitchen cabinet. Food was properly labeled and stored. The pantry is storing dishes. The facility has (2) refrigerators located in the detached garage behind the facility. The emergency food is stored and observed to be locked in the detached garage. Sharps were observed to be stored and locked in a kitchen top drawer adjacent to the kitchen sink. Fire extinguisher observed to be hanging on the wall in the dining room near the hallway, to have a purchase tag attached from Home Depot dated 05/20/2021. LPA observed no toxins, or anything being stored underneath the kitchen. A kitchen cabinet labeled “safety supply” to be locked and storing extra batteries, money, personal (Continued on LIC809C) care items and paperwork. Medications: LPA observed the locked medication cabinet at 1:49pm adjacent to the kitchen sink, the facility (2) first aid kits and manual located and stored in the medication cabinet. Bedrooms: At 1:58pm LPA observed all bedrooms to be appropriately furnished with sufficient lighting. LPA observed appropriately bed linen and comforters on all beds. One (1) out of three (3) bedrooms are single occupancy. All bedrooms observed to be clean and clear from obstruction. Bathroom: At 2:06pm LPA observed (2) bathrooms to be clean and in proper operation. (1) out of (2) bathrooms are labeled for employees only and are inaccessible to residents. LPA observed the appropriate grab bars in and around the toilet and shower also non-skid mats located in the shower area. The water temperature range was 115.2 degrees Fahrenheit. Hand towels are not shared. Bathrooms stocked and equipped with soap and paper towels. LPA observed the employee bathroom to have a locked cupboard storing cleaning supplies, incontinent supplies, and personal care items. Extra towels and linens are stored on a shelving unit above the toilet. Living, dining room and common areas: At 2:13pm LPA observed to be appropriately furnished with tables and chairs and adequate lighting. Observed to be neat and clean. Activities are stored in a cupboard in the dining room. File cabinets located in the dining room storing resident and staff files, clear from obstruction. At 2:19pm the fire alarm system was tested and observed to be working, it is hard wired and interconnected throughout facility. The facility has dual smoke/carbon monoxide detector located throughout the facility. Laundry Room: At 2:22pm LPA observed the laundry room, which is located outside near the ramp in the back of the facility in a locked rubber shed labeled “Laundry”, to be clean and clear from obstruction and storing laundry supplies. Garage: At 2:26pm LPA observed the detached garage to be locked and inaccessible to residents. The garage was clean, which had six (6) four (4) tier and (1) (3) tier shelving units storing the facilities extra non-perishable food, can goods, dry cereals, snacks, emergency food, personal care items, incontinent supplies, paper towels, tissue, cleaning products, water, and PPE. It is equipped with a refrigerator storing meats, vegetables, and fruit. Extra linen, towels, comforter are stored in the garage. (Continued on LIC809C) Backyard: At 2:38pm LPA observed a table and owning for seating, chairs, and extra table for lounging underneath a tarp providing a shaded area. Surrounding the facility was clean and clear from obstruction. It is also a space behind the facility being used as an office, it is equipped with a computer, printer, files etc. It also has a refrigerator storing bread, meats, and fruits. The facility has a rock fountain enclosed in a 3ft gate not being used, no bodies of water are located on the premises. LPA observed a small room located behind the rock fountain to be storing constructions supplies, tools, and storage bins. Exit interview conducted. Copy of this report issued