Routine inspection·October 25, 2023

Licensing Program Analysts (LPAs) Mariana Agban and Christopher Alemoh conducted an Annual Required visit and inspection of the facility. LPAs met with staff Carlo Magcalas and explained the reason for the visit. LPAs observed staff #1 (S1) cleaning the kitchen. Shortly after, LPAs met with Administrator Mercer Jones. At approximately 10:10 am, with the assistance of staff, LPAs took a tour of the physical plant, facility temp at 77 degrees. Required postings were observed in the entry area. The smoke alarms and carbon monoxide are properly functional. The fire extinguisher is located in the kitchen with date of purchase 3/3/2023. Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: The facility has five (5) bedrooms total. There were four(4) bedrooms designated for residents' use. One(1) bedroom is designated for staff. All bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are five (5) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 108, 109.102.7.111.3 degrees Fahrenheit. LPAs observed cleaning supplies under the sink cabinet not locked in the main restroom. Common Areas : These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds : Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Area : is located in the garage which is inaccessible to residents. Resident Files : LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files : LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. LPA observed that Staff#1 (S1) is not background cleared to work in the facility. Medications : LPAs observed that centrally stored medication records are missing required information. Deficiencies and civil penalty issued. Appeal rights given. Exit interview conducted and copy of this report delivered.