Post-licensing visit·February 9, 2024

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting a Post-Licensing Inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Administrator, Tiffany Vander Poorten, and explained the purpose for the visit. During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (6) resident medications, (6) resident files, (3) staff files, and conducted interviews with (3) staff, and attempted interviews with (6) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents. It has an approved Dementia Care Plan and a Hospice Waiver approved for (6) residents. There are currently (4) resident receiving hospice services. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file. LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home- both equipped with required grab bars and non-skid mats. The hot water was tested and measured between 114*F-119*F, which is in compliance. Food supplies was observed and was sufficient as required. No pools/bodies of water were observed on the premises. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. There is a fireplace in the living room covered with a screen. The last fire drill was conducted on 11/2023. Auditory devices were observed at all entrances/exits of the home and were operational. (6) resident files and (3) staff files were reviewed and observed to be complete with all required documentation. (6) resident medications were reviewed and were observed to be documented properly and given as prescribed. LPA reviewed the following, as part of the Post-Licensing Inspection requirement: Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures. No deficiencies were observed or cited, during today's visit. An exit interview was conducted and a copy of this report was provided.