Routine inspection·April 23, 2024

At 10:00 AM, Licensing Program Analysts (LPAs), Huma Rahimi, and Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. Team was greeted by the staff, Mari Akmakchyan, who granted access to the facility. LPAs explained the reason for the visit. This facility is licensed for the capacity of six (6) Ambulatory and one (1) Hospice residents. Upon arrival, Mrs. Akmakchyan informed LPAs that the facility currently has six (6) residents, of which four (4) are Non-ambulatory and one (1) is Bedridden. LPAs were also informed that only one resident (1) is on Hospice. At approximately, 10:10am team conducted a tour of the facility, and the following was observed: Common Areas : The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean and were properly furnished. No obstructions observed throughout the facility. The facility license was not posted and or available for review. Kitchen: LPAs observed sufficient supplies of staple non-perishable for 1 week and perishable for 2 days. At 10:15am, LPAs observed resident medications in a kitchen cabinet and Clorox along with other chemicals and detergents under the kitchen sink were kept unlocked and accessible to residents. Moreover, all knives and sharps in the kitchen drawer were kept unlocked and accessible to residents in care. There is a fire extinguisher by the kitchen that was last purchased on 05/25/2023. Bedrooms: There are three (3) bedrooms designated for residents use and have sufficient lighting. All bedrooms have appropriate bedding and linens. LPAs observed two (2) half rail beds in room #1 and only one resident had a doctor's order. Moreover, LPAs observed residents bed was blocking the emergency exit Continue on LIC809-C sliding door. In room #2, LPAs observed one (1) full rail bed and room #3 had two half rail beds, without physician's order on file. and one (1) full bed rail bed in room #3. Physician's order for half/full bed rails were not available upon request. Outside areas: At approximately, 10:40am team toured the outside area of the facility. LPAs observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Laundry: Laundry room is located outside and during the walk though, LPAs observed the room was kept unlocked and accessible to residents in care. Cleaning supplies were not locked. Resident Files: At 11:00am LPAs conducted resident and staff records review. The following was observed. Six (6) out of six (6) resident files were incomplete. Files were missing signatures and forms (such as Admission Agreement, Physician’s Report, Resident Preplacement, Appraisals/Reappraisal, List of personal property, ID Emergency Sheets, and Personal Rights. Resident appraisals that were in the file did not have services explained and were missing signatures from the resident, and or responsible party. Please see LIC858 included with this report. Staff Files: The following was observed. The Administrator has not renewed her Administrators Certificate since 08-26-2020. There are no completed personnel records for all 3 staff members which include the administrator. All three (3) staff files were missing First Aid Certificate and Mrs. Akmakchyan had required training on file. Medications review: At approximately, 12:30pm LPAs conducted a review of medication for residents in care. None of the six (6) residents had a completed centrally stored medication and destruction record. No First Aid Kit available for review. Administrative: Annual fees are past due. Last notice was mailed 01-03-2024 due by 03-18-2024. Amount of $742 is due immediately. Infection control plan is due immediately. Plans were due June 2022. LPAs collected a copy of Liability Insurance and LIC500. Deficiencies and civil penalty issued, see LIC809Ds. Exit interview conducted, appeal rights explained and copy of report signed and delivered.