Routine inspection·March 27, 2025

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced One (1) year Required visit at this facility. LPA met with Administrator Patria Dufrenne and explained the purpose of this visit. A tour of the physical plant was conducted at 9:33 AM and the following was observed: The facility is within a compound and has only one main gate entrance. There is only one main door of the facility being used. The screening station is located immediately upon entrance. The facility has an approved mitigation and infection plan on file. The facility is a single storey building with three (3) other Residential Care Facility for the Elderly (RCFE) facilities inside the compound. There are six (6) resident bedrooms, all private with own bathroom on each room. There is one (1) additional bathroom for common use. Resident bedrooms were observed to be appropriately furnished. The facility is fire cleared for six (6) non-ambulatory residents, all of which maybe bedridden. Hospice waiver for six (6) residents. Living and dining room furniture were checked. The living room is neat and clean along with the dining room. Furniture were observed to be in good repair and excellent condition. The facility maintains a comfortable temperature at 74°F. The dual smoke/carbon monoxide alarm are hardwired and interconnected, tested and observed to be operational. There is a Fire extinguisher located in the kitchen last bought on 03/26/25. The facility is equipped with sprinkler system. (continued on LIC 809-C) (continued from LIC 809) Food Service/Kitchen area was sufficiently stocked with 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. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Laundry area is located along the bedroom hallway. Laundry detergent, cleaning solutions and other toxins are observed to be locked in the storage area by the gate. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The Bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was checked and measured at a range of 107.4°F to 111.6°F Towels and washcloths are not shared. There were enough clean linen available in stock at the cabinet. Medications : LPA observed that the medication is kept in the other building (A Siwa) and was observed to be locked and inaccessible to residents. There was a complete first aid kit located in the office within the facility. Garage: There is no garage at the facility only car ports at the front area. The Backyard had a covered shaded area for clients with outdoor furniture. Sauna, and mini golf course. The swimming pool is appropriately fenced and was observed to be locked during visit. Client records . All six (6) residents record were reviewed and observed to be complete and current. Staff records were also reviewed and observed to be complete and current. Disaster drill was last conducted on 01/10/25. Required posting observed in facility (complaint hot line poster, personal rights, etc). Exit interview conducted. Copy of this report issued