Routine inspection·October 1, 2021

Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA was greeted and granted entry by care giver Esther Setyowati and reason for visit was explained. Upon entry LPA was screened per COVID guidelines. LPA tour the facility with care giver Esther Setyowati. The facility currently has 6 residents in care. Administrator Natalia Surgent arrived at the letter time. LPA observed residents watching TV in family room. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/sanitizer. LPA observed the screening/sanitizing station in the entrance of the facility. Visitors sign in and are screened for temperature. Facility takes resident temperatures daily and documents. Facility has COVID precaution postings as well as all required department postings. Facility has completed the Mitigation Plan and is approved. LPA observed adequate emergency food and water supply as well as the First Aid kit which contained all required items. Facility has all required items of PPE on site. LPA toured the outside grounds and observed ample shaded outside visitation area. Exit gate is unlocked and self latching. LPA observed the medication in locked closet. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation. Staff and most residents are vaccinated for COVID-19. Resident files contained updated emergency information as well as required department forms. Based on the observations made during today’s visit, no deficiencies are being cited in area inspected. This report was discussed with the facility representative and a copy was provided.