Routine inspection·January 9, 2025

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the staff member. The Administrator Stephanie Domingo was called. LPA stated the purpose of the visit was to conduct an annual inspection. The staff member confirmed there are two residents living in the facility. The facility is licensed for six (6) non-ambulatory residents. Two (2) of the six (6) can be bedridden residents. LPA Spaeth and the staff member toured the facility at 10:15 am until 11:00 am. Common Areas – The family room, dining room, and kitchen are combined. The family room is furnished with comfortable seating and a television. The dining room is furnished with a dining room table and chairs. Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a kitchen cabinet. Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher is located near the kitchen and was operable. The medications are locked in a cabinet and the knives are locked in a kitchen drawer. Cleaning solutions are locked underneath the kitchen sink. Continued on 809-C Laundry Room – The laundry room door has a key-punch lock system. LPA observed the washer/dryer and the laundry detergent were in the room. Garage –The garage was locked. The staff room is located within the garage area. Resident Rooms: There are four resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean. LPA Spaeth observed the resident rooms contain a sprinkler system. Bathrooms: There are three bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, and slip resistant mats. LPA observed the clean linens were located in a cabinet within the staff bathroom. Water Temperature: LPA tested the water temperature which was 105 degrees F. Surrounding Grounds : There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard. Smoke/Carbon Monoxide Detectors : The smoke/carbon monoxide detectors were tested at 11:20 am and were operable. LPA reviewed resident files at 10:45 am until 11:10 am. LPA observed a resident's document was missing from the resident file. LPA reviewed staff's file at 11:20 until 11:30 am. LPA viewed a resident's medication at 11:30 until 11:45 am. Based upon LPA's observations and upon Title 22 Regulations, the following deficiencies are substantiated. (See 809-D page). Exit interview conducted, appeal rights discussed, and a copy of the signed report was given.