Routine inspection·April 19, 2024

On 04/19/24, 9:01 AM Licensing Program Analyst (LPA) Raymond Comer conducted a required unannounced Annual visit to this facility. LPA met with Administrator, Khachatryan Verzhine , and reason for the visit was discussed. Facility is licensed as a single-story residence, Five (5) non-Ambulatory, with one (1) bedridden for a total of six (6) Residents. Hospice waiver for six (6). Facility has three (3) resident bedrooms, one (1) bedroom area for staff use, and two (2) bathrooms. At 9:10AM, LPA conducted a tour of the physical plant with the Administrator and observed the following: RESIDENT RECORDS are stored in secure and locked cabinet in dining room area and are inaccessible to residents. All Resident records were reviewed, and the following documents and information were missing: Physician’s Report and Resident needs and assessment plan documentation. STAFF RECORDS are stored in secure and locked cabinets in dining room area and are inaccessible to residents. Staff Records were reviewed and the following documents in information were missing: LIC 503 (Health Screening), LIC 501 (Personnel Record), and LIC 9052 (Employee Rights) documentation. LIC 809C-continued At 10:45 AM, LPA conducted a tour of the physical plant with the Administrator and observed the following: PHYSICAL PLANT was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 70.0°F. within the required range. Alternative exits are located in Bedrooms #2, #3, and #4 exiting to back yard. All trash cans are observed to be covered. An approved Mitigation and Infection Control plan was submitted by the Facility. Required postings are prominently displayed and observed to be current at the facility. COMMON AREAS: Entry and exit doors have a functional auditory alert when the doors open. Living room and Dining room areas are furnished with table large enough to accommodate the capacity of the facility. Living room is supplied with sitting area, television, stored games, and reading materials. LPA observed a fireplace in the living room area that is screened, preventing access. No fireplace tools present. Furniture and fixtures are clean and good condition. Facility telephone is observed as operational. KITCHEN area is clean and clear of clutter. LPAs observed a refrigerator, microwave, stove/oven, dishwasher and sink to be operational. Knives/Sharps are stored in a locked top drawer inaccessible to residents. Plates, cups, utensils, and two-day supply of perishable food is properly stored. A seven-day supply of nonperishable food is located in kitchen cabinet and properly stored. Dish Soap and cleaning solutions are stored in locked lower cabinet underneath the kitchen sink. FIRE DETECTION/SUPPRESSION SYSTEMS are present at facility. Dual smoke/carbon monoxide alarms are installed, hardwired and interconnected. Detectors were tested and function properly. Fire extinguisher is located on the wall near the kitchen and dining room. Purchase inspection service date: 04/22/2023 . LIC 809C-continued LIC 809C-continued MEDICATIONS are stored in a secured and locked cabinet located in the living room. Medications are inaccessible for residents. Two (2) first aid kits and manual are stored in medication cabinet . LAUNDRY area is located outside in storage area. Laundry space observed to be clean and clear from obstructions. Soaps and other cleaning agents are stored and inaccessible to residents. A supply of linen and towels are observed to be in adequate supply. BEDROOMS : Bedroom#1 and Bedroom#2 are shared resident rooms. Bedroom#3 is a private resident room, and Bedroom#4 is used by Staff. All Bedrooms are observed as clean with sufficient lighting, properly furnished with bedding, linens, at least one chair, and nightstand. BATHROOMS were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 104°F. Within the required range. GARAGE is detached from the house and observed to be locked and inaccessible to residents. Garage is storage for miscellaneous items. OUTDOORS: Backyard area observed to be clean and clear from debris and obstruction. Outdoors maintains a shaded area with patio furniture observed to be in good condition and sufficient seating for residents. Backyard contains a swimming pool whose perimeter is fenced, and entry gate secured and locked, inaccessible to residents. (See LIC809D for Deficiencies Cited) . An Exit Interview was Conducted, A copy of the Facility Report and Appeal Rights were provided to the Administrator.