Routine inspection·April 2, 2026

Licensing Program Analysts (LPAs) Angela Panushkina, Huma Rahimi, along with the Fire Inspector, Frank Madugno and Building Engineering Inspector, Robert Hagen, conducted an annual-continuation inspection and met with the Co-Administrator and explained the reason for the visit. The facility is Fire Clearance was approved in 10/22/2019 for the capacity of one (1) Bedridden and one (1) Non-Ambulatory residents in room #1, two (2) Non-Ambulatory residents in room #2, one (1) Non-Ambulatory resident in room #3 and one (1) Ambulatory in room #4. A tour of the physical plant was initiated at 10:15am and the following were observed: The facility maintains a comfortable temperature at 68°F. The facility has four (4) bedrooms designated for residents’ use. All bedrooms are furnished with beds and dressers and required bedding and linen. The bedrooms have sufficient closet space and lighting. Auditory alarms were tested and observed to be operational. The team observed a twin bed in bedroom #1’ closet. The Co-Administrator informed the team that the staff are using the closet area as a resting area for breaks. The team also observed four (4) bottles of vitamins/over-the-counter medications along with Raid and disinfectant sprays placed on the table, unlocked inside the walking closet. Additionally, self-closing fire door hinge was loose/broken and had a stopper underneath the door to prevent from closing during the emergency. The Co-Administrator was informed to replace/repair the door. Lastly the team observed R1 had a full bed rail with no doctors' order/exception of file, double ½ (half) bed rails (making one full bed rail) for R2 with no doctors' order on file, ½ (half) bed rail for R4 with no doctors' order on file and ½ (half) bed rail for R3 with no doctors' order on file. Deficiency will be issued. Continue on LIC809-C There are three (3) full bathrooms. All bathrooms were observed to be clean and in good repair. Properly supplied with toilet paper, soap and paper towels. The hot water temperature measured at 113.2°F. Appropriate grab bar and non-skid mat were also observed. All trash cans in bathrooms had fitted lids to protect them from cross contamination. Extra towels and linens were readily available. The facility has a kitchen area that is equipped with a refrigerator, microwave oven and sink. The team observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. At 11:20am, LPAs observed twenty-one (21) prefilled syringes of ready-to-administer, single-dose unit narcotic medication prescribed for R1. The fire extinguisher is located in the kitchen and was last serviced on 07/25/2023. Deficiency will be issued. At approximately 11:30am, LPAs observed medications are centrally stored and locked, in the kitchen cabinet, and inaccessible to residents in care. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. The laundry room is located by the garage. The washer/dryer appears to be in good condition. The laundry area was observed to be unlocked, and all laundry supplies and chemicals were accessible to residents in care. The team observed another twin bed in the garage. The Fire Inspector informed the Co-Administrator that the garage is not approved for a habitable space. Additionally, the Fire Inspector informed the Co-Administrator that the occupancy for the facility is incorrect, and new Fire Clearance is required at this time. The Deficiency will be issued. These include a dining area and a living room. The Common areas are furnished with adequate furniture to accommodate a maximum capacity of six (6) residents. At 11:40am, smoke and carbon monoxide detectors were tested and observed to be operable. There were no visible immediate hazards. At approximately 11:45am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining care and supervision to meet the needs of clients. There are no bodies of water. Between 12:30pm to 1:30pm, LPA reviewed records of six (6) residents and two (2) staff. Resident and staff records appeared to be incomplete (missing forms, signatures, dates and S1's & S2's initial training). Deficiency will be issued. LPA collected Certificate of Liability Insurance and LIC500. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.