Routine inspection·February 26, 2025

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on February 26, 2025 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was unavailable to be present- spoke with LPA by phone. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA found the water temp to be 120'F in resident bathroom. Advised caution and monitoring. LPA advised that the current Administrator's certificate be posted. LPA reviewed two (2 ) resident and one ( 1) staff files. Two resident files were not present at the facility (R2 and R4). Licensee to submit the following for R2 and R4: Physician's assessment, pre-appraisal and appraisal/ needs and services plan. S1 was found to have current 1sr aid but not CPR. S1 is working alone and CPR is required. LPA requested the following documents to update the facility file: LIC 500, liability insurance certificate and updated plan of operations for new dementia regulations. LPS provided Dementia Care flier and advised review of PIV24- 09-ASC. As a result of this inspection, the following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview conducted with caregiver/ designee and copy of report and appeal rights left at the facility.