Routine inspection·October 3, 2022

Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Samantha Alex (Administrator) and explained the purpose of the visit. FACILITY LICENSED TO SERVE ELDERLY RESIDENTS AGE 60 AND ABOVE. FIRE CLEARANCE APPROVED FOR 6 AMBULATORY RESIDENTS. During today’s visit, LPA observed the following: Physical Plant and Environmental Safety : Sufficient lighting, non-skid maps in bathroom, comfortable temperature, Hot water temperature measured at 136.4 degree F in the hallway bathroom. LPA observed 2 live cockroaches in the Resident records. Operational Requirements : Facility has an approved fire clearance. Staffing : There is sufficient staff, the administrator is on the premises during normal business hours. Personnel Records - Training : Staff #1, #2 did not have current first aid/CPR training and LPA did not observed a health screening for Staff #2. Resident Records/Incident Reports : Admission agreement, medical assessment and appraisal observed. Resident Rights/Information : Complaint poster (PUB 475) posted on wall next to the garage entrance, resident's personal rights in file. Planned Activities : Facility has sufficient space to accommodate indoor and outdoor activities, furnished areas is provided for relaxation of residents and entertaining friends and relatives. Food Services : Perishable foods are stored in covered containers, toxins are stored separate from foods, kitchen is kept clean. Resident with Special Health Needs : Hospice care plan is current, items that can constitute a danger is inaccessible to residents. Incidental Medical and Dental : Licensee provide assistance in meeting medical and dental needs for residents, all centrally stored medications is labeled and maintained in compliance with state and federal law. Per Title 22 Regulations, the deficiencies observed are documented on LIC809D. Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted and a copy of this report and appeal rights provided to Samantha Alex.