Routine inspection·February 1, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with and explained the reason for the visit. The facility is licensed to served (6) non-ambulatory residents over the age of 60, of which (1) may be bedridden, with a hospice waiver for (4). The facility is a single home located in a residential neighborhood and consist of a living/dining room area, a kitchen, (4) resident bedrooms, (4) resident bathrooms, (1) staff/visitor's bathroom, a front porch, a backyard, and a detached garage. LPA toured the facility with an observed the following: Facility is in good repair indoor and outdoor. Passageways, ramps, exits are free of obstruction and debris. Living/dining room has sufficient sitting area, and fire place is covered. A linen closet was observed. Kitchen area is clean. Sharps, cleaning supplies, and medication were observed locked. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Laundry room is located in the basement and additional grooming supplies were observed. Each room (4) was observed with the required furniture, and sufficient lighting. Resident #2(R2) in room #2 was observed with bed rails and a request was not on file. Each resident bathroom (4) was observed in working condition, with grab bars and skid mats and water temperature was tested between 113.5-126.1 degrees F. which is not within the required 105-120 degrees F. All required posting was observed throughout the facility. Carbon Monoxide/ Smoke detectors were observed, tested, and in working condition. Fire extinguishers were observed and last checked on 1/17/24. Backyard has a sitting area and front porch provides a cover sitting area. LPA reviewed medication and files for 5 residents. Resident #5(R5) was missing a pre-placement assessment. Files for 5 staff were reviewed. Administrator certificate #6066207740 exp. date: 9/8/25. Infection control plan and Emergency Disaster plan were reviewed and were updated within the last year. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Sako Manvelyan and a copy of this report, LIC 809D, and appeal rights were provided.