Routine inspection·November 22, 2023

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry by DSP Imelda Delrosario. Facility Manager Sarah Levante joined the inspection during the tour. The facility is a one-story home with four resident bedrooms, two bathrooms, kitchen, dining room, living room, laundry room, staff office, back yard and attached two-car garage. Facility appeared clean, sanitary and well-organized. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels. Hot water measured at 105 degrees Fahrenheit in both bathrooms. LPA issued a technical assistance requesting that the staff closely monitor the water temperatures to remain in compliance and obtain a new water thermometer. LPA observed exit gates in the backyard to be operational and unobstructed. Facility has three shaded seating areas in the backyard. Smoke and Carbon Monoxide detectors tested operational. LPA observed facility has emergency food and water supply. Laundry machines are operational. Facility has a 2-day supply of perishable food and a 7-day supply of non-perishable food. Fire Extinguisher was observed to be fully charged as indicated by the built-in meter. The service tag indicates it was last serviced on 10/31/23. LPA reviewed medication and files for all four clients. Facility manages money for two of their residents. LPA reviewed P&I with Facility Manager. The P&I appeared accurate after the Facility Manager updated the ledger for one client. LPA used the ledger’s history to verify the validity of the Facility Manager’s update. A Technical Assistance was issued regarding P&I. LPA reviewed five staff files. LPA observed two out the five files had current First-Aid/CPR certificates, the other three did not. Facility Manager stated they will have staff complete First-Aid/CPR training. A Technical Violation was issued. LPA observed the disaster drill records, which indicate the last time a drill was completed was in May of 2023. A deficiency is being issued on this day. Based on today’s inspection, one deficiency one technical violation and two technical assistances were issued. An exit interview was conducted and a copy of this report was provided.