Routine inspection·July 3, 2025

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required 1-Year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the evaluation, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms, and temperature was checked. LPA Bunker met JoAnn Tito, Roberto Rito, the Caregivers, and Sheryl Tongo, the Administrator. LPA Bunker explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Plan. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for (1) ambulatory and (5) non-ambulatory residents. The facility has a hospice waiver for 2 residents. There are currently four (4) residents in placement. The facility's annual fees are current. The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirement, Physical Plant & Environmental Safety, Staffing, Personnel Records-Training, Resident Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records-Incident Reports, Disaster Preparedness, Resident with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections. The facility is a single-family home located in a residential neighborhood. Caregivers JoAnn Tito, Roberto Rito, and LPA Bunker toured the facility which consisted of the following: Living room, dining area, kitchen, sitting area, 6 residents bedrooms, 1 staff bedroom, 2 client bathrooms, 1 staff bathroom, laundry room, backyard has a shaded area with patio furniture, a table and six chairs, and a indoor/outdoor activity areas. See continued LIC809-C on page 2 Continued LIC809-C page 2 The front and back yard landscape is in good condition at the time of the visit. During the tour, LPA Bunker observed a sanitizing station, hand sanitizer, visitor sign-in log, and thermometer at the facility's front entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. The administrator indicated that the staff reviews the PINS and are up to date on them. Documents are posted as mandated on the walls in the dining area. Bedrooms contain the furniture mandated, and bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-slip surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are in a locked cabinet in the hallway, and records are current. Common areas were observed for the ability to safely serve the needs of the clients, including cleanliness and clearness of any potential hazards to the residents. The first aid kit is fully stocked with a manual, hardwired smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 113.1 degrees Fahrenheit within the normal limits (105-120 degrees), the fire extinguishers are fully charged, adequate linen supply, the facility telephones are working. The resident's bedroom windows have no sliding window lock with thumbscrews; all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff were given training on dependent adult and elder abuse reporting. The facility conducted a fire drill on April 07, 2025. There were no deficiencies cited. An exit interview was conducted, and a copy of this facility evaluation report was provided to Administrator Sheryl Tongo.