Post-licensing visit·May 10, 2024

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced visit for the purpose of a post-licensing inspection. LPA met with Administrator, Andrew Mente, and explained the purpose of the visit. The fire clearance has been approved for a capacity of 6 residents, which 5 may be non-ambulatory and 1 bedridden. Bedroom #6 is approved for bedridden. The hospice waiver is approved for 4 residents. The facility is a single story home with 6 private resident bedrooms, 1 staff room, 4 bathrooms (2 communal bathroom, 1 in bedroom #4, and 1 jack and jill bathroom), living room, dining room, kitchen, and attached garage. The facility has a swimming pool in the backyard and is surrounded by a locked gate. The bathrooms have non-skid mats in the shower area and grab bars. The backyard has a shaded area with table and chairs. Facility has an operable smoke detector in each room and a carbon monoxide detector located near resident rooms. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to residents. The facility has auditory devices located by the exit doors and in each of the resident room's sliding doors. There is a sufficient food supply of 2 day perishable and at least a week of non-perishable food maintained at the facility. Staff and Residents files are stored and maintained at the facility. LPA reviewed resident and staff files to ensure all required forms are in their files. Medications are centrally stored and locked inside a kitchen cupboard. LPA reviewed medications and there are no discrepancies. The facility accepts and retains residents with dementia and/or hospice. The facility has a "no smoking oxygen in use" sign posted at the facility and in front of the resident's room. Emergency Disaster Plan is easily accessible and disaster drills are conducted quarterly. No deficiencies are issued today. An exit interview was held and a copy of this report was given to the administrator.