Routine inspection·November 28, 2023

At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit and met with Staff Member, Tigist Dinka. Administrator, Martha Ghezzehai, arrived during visit at approximately 10:00AM. Facility is a Residential Home for the Elderly and provides care and assistance for Older Adults . Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 4 residents in care, and 2 staff members on-site. At approximately 9:40AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:45AM, LPA conducted a walk-though of the facility. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 6 Resident bedrooms, 4 bathrooms, a staff break room and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Toxins and other hazardous items were observed to be stored inaccessible to residents in care. Mattress pads were in place or available for Resident use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. At approximately 10:30AM, LPA reviewed 5 staff files, 4 resident files and resident medications. 4 of 5 staff files reviewed were found to be well organized, thorough and contained the required documentation. LPA observed that 1 of 5 staff files did not have a Health Screening form (see Technical Advisory, LIC9102, Regulation 87411(f)). Staff files had current First Aid and CPR certification. LPA observed that all resident files were found to be well organized, thorough and contained the required documentation. Resident medications were found to be centrally stored and secure. LPA conducted interviews. Facility's fire extinguishers were found to be last inspected February 2023. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last fire drill was conducted October 2023. Continued on LIC809C Continued from LIC809 Review of Administrator Certificates for Martha Ghezzehai (6060357740) and for Miriam Ghezzehai (6060459740) show that their re-certifications are pending with the Department of Social Services. LPA is requesting the following documents to update facility file: Updated Lease Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificates when available Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 12/28/2023. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC9102 (Technical Advisory/Violation) discussed and provided to Administrator. Signature on form confirms receipt of documents.