Routine inspection·September 1, 2023

On 09/01/2023, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual required visit using the new CARE Inspection. LPA spoke with Administrator Catherine Espino over the phone explained the purpose of today’s visit. The facility is licensed to operate for six (6) nonambulatory of which two (2) may be bedridden in any room. The facilities annual fees are current. LPA and Caregivers (S2 and S3; reference LIC859) toured the physical plant. This facility consists of five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, kitchen, living room, dining area, office area, shaded patios (located in the front yard and backyard), and a two car garage. One fire extinguisher last serviced on 2/10/2023 is located near the kitchen. There were no bodies of water on the premises. A comfortable temperature was maintained in the facility. LPA conducted a records review of (5) client records and (5) staff records (LIC 500 Roster and two staff files were unavailable). LPA reviewed (5) Client Medication Administration Records and observed discrepancies at the time of visit. Deficiencies were observed during today’s visit but due to time constraints an Annual Continuation visit will be conducted. A copy of this report, review of staff/volunteer records (LIC 859), and resident’s records review (LIC 858) was provided to the facility.