Routine inspection·October 13, 2024

Licensing Program Analyst (LPA) Gary Tan, met with Administrator Celia Oyibu for a One (1) Year Required visit for this facility. LPA arrived and was greeted by staff Cyrus Domah and explained the reason for the visit. Ms. Oyibu arrived approximately ten (10) minutes later. There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. A tour of the physical plant was conducted with the administrator at 9:35 AM. The facility is a single storey building with four (4) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bedroom and one (1) bathroom is designated for staff use. The facility is fire cleared for two (2) non-ambulatory residents, one (1) of which may be bedridden. Hospice waiver for two (2). Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 77°F. The smoke detectors are hardwired and interconnected and observed to be operational. The fire extinguisher is located in the laundry room and was last 08/22/24. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water at the facility. (continued to LIC 809-C) The garage is converted into an additional dwelling unit (ADU) which a family member/staff is currently living. It is also currently being used as frozen food storage. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Fire extinguisher is located at the kitchen and observed to be full and current. Laundry room is located adjacent to the kitchen. Laundry soap, chlorine and other cleaning agents were stored on the cabinet above the washing machine and was observed to be locked and inaccessible to residents. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amount of personal hygiene product which is provided by the licensee. Staff Rooms: Staff room was observed to be locked and inaccessible to residents. No medications are observed in the staff room. The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at 118.5°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet. Medications : LPA observed medication in the cabinet in the hallway in between residents’ room to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There was a complete first aid kit located in the medication cabinet. Client records : Client records were reviewed. Resident #1 has a Dementia diagnosis but no updated LIC 602 on file. Staff records : LPA conducted a complete file review of staff records. Staff #1 (S1) has no LIC 503 on file. Disaster drill was last conducted on 08/30/24. Required posting are observed to be complete and current and displayed properly at the facility. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.