Routine inspection·April 17, 2025

Licensing Program Analyst (LPA) Elizabeth Irra conducted an annual inspection visit. LPA met with Cholly Sason and discussed the purpose of today’s visit. Tiffany Vander Poorten (Administrator) arrived at approximately 9:05 A.M.. This home is a single-story home with a fire clearance for (6) non-ambulatory residents. This home also has an approved Dementia Care Plan and a Hospice Waiver approved for (6) residents. There are currently (2) residents receiving hospice care. There are (3) residents receiving Home Health Agency services. LPA obtained a copy of a current liability insurance coverage. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has an Infection Control Policy in place and was observed to be posted. Operational Requirements: Facility is adhering to the operational requirements. Physical Plant & Environment Safety: LPA toured facility grounds. Fire smoke alarms and carbon monoxide detector (located in the hallway) observed. The fire extinguishers were observed and appeared to be full (one located near the kitchen/dining area and one located inside the laundry room). Last drill was conducted on 01/22/25. Bedrooms have the required furniture. Ample supply of food (perishable and non-perishable) was observed. Ample linen supplies were also observed. Bathrooms have non-skid surfaces and grab bars. Hot water temperature measured at 106.8* and 107.4 * in the hallway bathrooms and 106.5* in the bathroom inside bedroom # 4. ***Refer to LIC 809C for the continuation of this report***. Staffing : Facility is adhering to staffing requirements. Personnel Records-Training : Staff files are maintained at the facility. LPA reviewed staff files for S-1 through S-5. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Resident Rights-Information: Resident rights are posted and are included in Resident files. Planned Activities: Activity provides planned activities. This facility also provides internet access to the clients. Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating. Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #5 (R-5). Resident files are maintained at the facility. Resident file has the required documents. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment and Preplacement Appraisal Information, Resident Pre-Appraisal. Resident Rights were observed. Disaster Preparedness: The facility has a Disaster Preparedness plan in place. Health Related Services/Incidental Medical Services: The medications are stored and locked. Medications are administered as prescribed. Exit interview conducted, copy of appeal rights and a copy of this report was provided to Tiffany Vander Poorten (Administrator).