Routine inspection·December 6, 2024

Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 12/6/24. LPA met with Staff, Jennifer Discipulo, and explained the reason for the visit. Administrator, Jas Singh, arrived shortly after to assist with the visit. The facility is licensed to serve 6 non-ambulatory residents ages 60 and over. There is an approved hospice waiver for 6 residents. LPA conducted a tour, reviewed files and medications using the Compliance and Regulatory Enforcement (CARE) tools. The faciity consists of 5 resident bedrooms, 1 staff room, 3 bathrooms, living room, dining room, family room, kitchen, and laundry area. The backyard has a shaded area with table and chairs for residents to use. The bedrooms have sufficient storage space and lighting. Bathrooms have grab bars and non-skid mats. There are extra clean linens stored in the cabinet. Knives and cleaning products are locked. There is a carbon monoxide detector located near the kitchen and smoke detectors are operable. Sufficient food supplies are observed. The hot water temperature was measured at 127.4 degrees F which is above the required range. LPA reviewed all 6 resident files and their medications. The files contain the required documents and medications are being given as prescribed. The resident rights, local ombudsman, and licensing posters are located in a prominent area. LPA reviewed 3 personnel files. The administrator's (Jas Singh) certificate expires on 4/11/25. Staff have current CPR & First Aid certificates. Files contain the health screening with TB test results, personnel report, and annual training verification. Facility accepts and retains residents with dementia. There are no residents on hospice at this time but some are receiving home health services. No residents have a restricted or prohibited health condition. The facility has the updated Emergency Disaster Plan and signed annual by the administrator. Disaster drills are being provided to staff. A deficiency is being issued on the LIC809D. An exit interview was held and a copy of this report was given to the administrator.