Routine inspection (multi-day)·July 31, 2024

During the interview with Caroline she was asked how many residents were in her care and she said that she had a census of five (5) which included Adam Barone, but when obtaining files Caroline only had incomplete files for Resident 1(R1),Resident 2 (R2) and Resident 3 (R3). Caroline said that she had to leave and allowed her caregiver Danica Reyes to provide LPA with documents needed and to sign the annual report. LPA observed Resident 1 (R1) in a bedroom that was not approved/cleared by the fire department for non-ambulatory clients in care. Per the approved fire clearance dated 3/30/2023 bedroom #4 is the only room approved for non-ambulatory residents which is currently being used by Caroline Armstrong-Administrator. Medications are kept inaccessible to clients. Overall, the facility is clean and in good repair. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Record Review: LPA reviewed (3) client files for admission agreements, updated physician reports, and needs and services plans .R1, R2 and R3 files were incomplete. LPA attempted to review files for staff member(s) but there were no files available for review. Care & Supervision: Facility had sufficient care staff at the time of annual inspection. The staff members working in the facility had criminal record clearance through the department. The annual inspection was completed on 7/31/2024 and the administrator Caroline Armstrong was called during the inspection. Caroline was asked if Adam Barone was still allowed to reside or allowed to enter the facility since receiving the exclusion letter and she stated Yes and he is being allowed to stay at the home because he is currently a client not a staff member. Caroline was informed that fee's of $100 a day will be assessed from 6/3/2024 until Adam Barone is disassociated from the facility for not complying with the exclusion letter issued on 6/3/2024. Caroline was also informed that disassociation through Guardian is required to clear the plan of correction within 24 hours. Caroline said that she will appeal because Adam is no longer a staff member. Caroline was informed on 7/19/2024 annual fees were required to be paid and has not been as of 7/31/2024. Caroline was issued civil penalties for not paying past due annual fee's. An exit interviewed was conduct where this report was discussed and provided to the Danica Reyes at the conclusion of the visit.