Routine inspection·March 30, 2022

Licensing Program Analyst (LPA) Abeye Duguma met with the Administrator's Assistant, Ronie Luna, 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 4:00pm 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 backyard. The facility has sufficient stock of PPE in a storage room located in the storage closet near the front entrance . The facility has a total of five (05) bedrooms, of which one (01) is a staff room and a total of two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) ambulatory, of which three (03) may be non-ambulatory, one (01) may be bedridden and a hospice waiver for six (06). The facility is currently occupying five (05) non-ambulatory residents, of which one (01) is bedridden and three (03) are 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 laundry and storage . Laundry detergents, cleaning agents and other toxins are stored in the locked garage . 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 cabinet 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 70 °F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located, observed to be full and last inspected on 10/07/2021 . Staff rooms were observed to be locked and located near the living room area. No medications are observed in the staff room. 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 . The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 116.2 °F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinet . LPA observed medication to be locked and inaccessible to residents, located in the hallway cabinet . There is a complete first aid kit located in a locked cabinet near the family room. Exit interview conducted. Copy of this report issued.