Routine inspection·February 6, 2023

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus on the Infection Control Domain. LPA arrived unannounced and met with Staff, Anna Phiri, who allowed entry. Administrator, Linda McIntosh, arrived at approximately 11:00 am to assist with the visit. The facility is licensed to serve residents ages 60 and above. The fire clearance is approved for 6 non-ambulatory residents and the facility has a hospice waiver approved for 5 residents. The facility consists of 4 resident bedrooms, 2 bathrooms, living room, dining room, kitchen, family room, and an attached garage. The upstairs is utilized as the Administrator's office and living space for live-in staff. The swimming pool in the backyard is surrounded by a gate. The facility submitted a mitigation plan in which they are still following. The inspection consisted of the following: Screening and temperature logs were observed for both visitors and staff. COVID-19 signage were posted at the front entrance and throughout the home. There were sufficient food supplies of 2-day perishable and a week of non-perishable observed. Each resident bedroom had the required furniture and is well maintained. PPE supplies for at least 30-days are in storage at the home. Sharps, knives, and cleaning solutions were locked in the cabinet under the stove. Medications were locked and centrally stored. LPA reviewed the medications for all 5 residents and there were no discrepancies found. Fire extinguishers were observed to be fully charged and last inspected on 5/12/2022. The smoke and carbon monoxide combo detectors are operational. LPA observed all staff and visitors wearing a face covering during the visit today. The resident files have updated contact information. Per the Administrator, they are able to obtain additional staffing if needed. LPA did not observe any deficiencies today. An exit interview was conducted and a copy of this report was given to Administrator McIntosh.