Routine inspection·March 27, 2025

On 3/27/2025, At 1:14 PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced annual comprehensive inspection. Upon arrival LPA called the facility introduced herself, explained the purpose of the visit and was granted access into the facility gates. LPA was greeted by Alzaneh Zerabi- Receptionist upon entering the facility. LPA was greeted by the Luz Rose-Administrator who was informed of the purpose of the visit. The facility is licensed to serve 136 non- ambulatory residents of which 6 may be bedridden. The facility has an approved hospice waiver for 12 residents. Currently there are six (6) bedridden, five (5) residents are on hospice. There are currently no residents who have dementia, and five (5) residents are receiving home health services. The facility does not handle any of the residents’ money. The current census is 64. At 1:40 PM, LPA reviewed seven (7) residents files for admission agreements, updated physician reports, needs and services plans all of which were all current. LPA also reviewed seven (7) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings which were all current. At 2:55 PM, LPA conducted a random audit of seven (7) residents Medication Administration Records (MARS) which appeared residents have been given their medications as prescribed by their physicians. At 3:15 PM,LPA and Luz Rose-Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of seven (7) bedrooms and seven (7) bathrooms and the bathrooms were found to be clean and operational. The bedrooms have the required furniture which appeared to be in good repair. The rooms also have adequate lighting, and storage for the residents’ personal belongings. LPA toured the kitchen and dining area and there was sufficient seating for dining. There was a menu available for review. LPA observed a 5-day supply of perishables and a 7-day supply of non-perishable food available for the residents in care which was adequately maintained. All fire extinguishers were fully charged and operable. The last fire inspected was on 3/17/2025 and the smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115.5°F to 116.2°F throughout the facility and the temperature ranged from 74°F to 78°F. During the visit, LPA observed that the facility was clean, sanitary, and appropriately furnished. LPA also, observed cleaning supplies, toxins, and sharp objects were stored inaccessible to residents in care. Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted, and this report was discussed and provided to Luz Emma Rose-Administrator at the conclusion of the visit with appeal rights.