Routine inspection·October 14, 2024

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff contacted Licensee/Administrators (AD) Margie Santos via telephone who arrived a short time later and was present for the visit. During the inspection, LPA Haley observed a locked closet right next to the front door with resident medication, resident P&I funds, and a first aid kit with all the required elements. All resident bedrooms were clean, organized, and had the necessary elements and were in compliance with regulation guidelines. Resident bathrooms were clean and organized as well. Hot water temperatures were measured at 108.5 degrees Fahrenheit. Grab bars were tightly secured to the wall, and hazardous items are locked under the sink and inaccessible to resident in care. The kitchen is clean, organized, and a perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in a cabinet below the counter. There was another cabinet below the sink with a supply of towels and additional clean linen. Knives and sharp objects are kept locked in a cabinet near the stove. Hazardous cleaning materials are kept locked under the sink. In between the kitchen and the exit door that leads to the backyard, there’s a small laundry room. In the laundry room a washer and dryer was observed. On the side of the washer, there’s an emergency supply of nonperishable food items, and an emergency bag ready to go incase of emergency. Above the washer there’s a locked cabinet with additional cleaning supplies. The garage is locked and inaccessible to residents at all times. The garage was organized, free of clutter and walkways are free of obstruction. Continued on LIC809C There’s an office area set up with a desk and a printer. Staff and resident files are kept locked in the garage. Miscellaneous items were observed including, wheelchairs, additional COVID supplies, adult diapers, and other facility items. An additional refrigerator with an additional supply of food items was observed in the garage. The backyard was clean, organized, and walkways were free of obstruction. A shaded patio area with tables and chairs was observed. There’s a locked storage area in the backyard that remains locked and used to store miscellaneous facility items. LPA observed a mattress, walkers, wheelchairs, and holiday decorations in the locked storage space. Side exit gates are self-closing and self-latching. No bodies of water was observed. Smoke detectors, and the carbon monoxide detector tested operational. A fully charged fire extinguisher was observed mounted on the wall in the kitchen near the sink. Emergency evacuation drills are conducted on monthly. The last evacuation drill was conducted October 5, 2024. During the inspection, 4 resident files were reviewed, 4 resident medications reviewed, 4 resident P&I funds were reviewed, 4 staff files were reviewed, and 3 staff were interviewed. No deficiencies are being cited as a result of today’s visit. An exit interview conducted, and a copy of this report was provided to Licensee/Administrator Margie Santos.