Routine inspection·January 28, 2025

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection . The LPA was greeted by Administrator Erika Ramos, notified her of the purpose for the visit and were allowed to enter the facility to conduct the inspection. Facility Overview: The facility is a single story building with four (4) residents bedrooms, two(2) bathrooms, a common area, a dinning room and a kitchen area. There is no gated pool and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen inaccessible to residents. The smoke detector and carbon monoxide detector were operational. LPA observed fire extinguishers to be in compliance with the department requirements and with an expiration date of February 12, 2025. The water temperature was tested within regulations. Continued 809-C...... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of July 21, 2025 and a CPR certification with the expiration date of January 9th, 2027 Record Review and Resident/Staff Files: LPA reviewed files for two(2) staff members, confirming criminal clearances, and CPR/First Aid certification. Three (3) residents' files were reviewed and were missing the needs and service plan. A technical violation will be issued . LPA observed first aid kit to meet the department's requirement. The residents and staff files were kept in the hallway and inaccessible to unauthorized individuals Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the kitchen area. LPA reviewed medications for four residents, confirming that all medications were listed and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 12-2-2024, which met department requirements. All facility exits were clear of obstructions. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Administrator Erika Ramos.