Routine inspection·March 7, 2024

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff and explained the reason for the visit. Staff informed LPA that they were unable to understand English and called Administrator LUSINE MELIKSETYAN who could not attend today's visit. Administrator Designee Ruzanna Manukyana arrived shortly after. At 10:10 AM LPA took a tour of the physical plant. Required postings were observed in the entry area. LPA observed dining room ceiling had water stains and cracks in the ceiling. Staff had an empty packet in the middle of the floor to gather the water dripping off the roof. LPA asked the Administrator Designee regarding the roof leaking and when it happened. Administrator Designee stated that the leak happened last week due to the rain. Administrator Designee stated that the property owner will fix the roof when the rain stops. LPA advised the Administrator Designee that this poses a potential health and safety to residents in care. Kitchen: The kitchen appliances and fixtures were functional. LPA 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 office cabinets. The fire extinguisher is located in the kitchen with a purchase date of 7/11/23. Smoke alarms and carbon monoxide were tested and are functional. Bedrooms: The facility has four (4) bedrooms of which one is a shared room. All four (4) bedrooms were toured and appear to be clean and properly furnished. Bathrooms: There are two (2) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 113.8 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. 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. The laundry room: was locked and inaccessible to residents. Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date. LPA observed that S1 and S2 are not on the training list for February Administrator Designee stated that they have taken training's but their names were not on the list. LPA also observed that S1 and S2 had not signed any of the training's that the Administrator Designee stated they took. In addition, LPA oberved there's no physical file of Administrator Designee. Medications: Medication and Medication Records were reviewed for proper documentation. LPA observed that R1's centrally stored medication and destruction record is missing all information regarding the medication name and start date. R2's centrally stored medication and destruction record is missing the start date. R3 Buprenorphine Medication was missing doses for March 11,12,13, and 14. The Buprenorphine medication is instructed to take one tablet daily. LPA was informed that the staff had a doctor's order to give this medication twice a day instead of once. LPA requested to see medication instructions change but staff couldn't provide them. LPA also observed that Quetiapine is missing 56 tablets. Exit Interview Conducted, citations issued, copy of the report delivered and appeal rights given.