Routine inspection·December 16, 2021

Licensing Program Analyst (LPA) Abeye Duguma met with the Administrator, Jilska Parera for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:00am and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. 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 outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a cabinet near the dining area . The facility has a total of four (04) bedrooms, all utilized by residents and three (03) bathrooms for both residents and staff. The facility is fire cleared for one (01) bedridden and one (01) non-ambulatory in room #1, two (02) non-ambulatory in room #2, (01) non-ambulatory in room #3, one (01) ambulatory in room #4 and a hospice waiver for six (06). The facility is currently occupying five (05) residents of which four (04) are non-ambulatory and under hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. The garage is being used for storage . Laundry detergents, cleaning agents and other toxins are stored in a cabinet in the laundry room . Kitchen area was sufficiently stocked with at least 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. (continued on LIC 809-C) Knives and sharps are observed to be locked in a drawer inaccessible to residents. 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 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the kitchen nook, observed to be full and last purchased on 06/14/2021. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee and responsible parties. The bathrooms were checked for cleanliness and proper operations. The hot water temperature was measured at 118.8°F. Towels and washcloths are not shared. There was enough clean linen available in the master bedroom's walk-in closet. LPA observed medication and first aid kit to be locked and inaccessible to residents, located in a cabinet near the kitchen nook. Exit interview conducted. Copy of this report issued.