Routine inspection·January 15, 2025

On1/15/2025 at 12:20 PM, Licensing Program Analyst (LPA) Beena Singh conducted an unannounced annual required visit. LPA was greeted and granted entry to the facility by Administrator Ta'Neisha Riley . LPA Singh explained the nature of today's visit. LPA Singh accompanied with Ms Riley, conducted a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility was not operating over capacity or beyond any conditions and limitations on the license. The pools and other bodies of water located on the premises and secured gates and are in compliance with regulation. Facility is being maintained at a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature was measured at 115 degrees Fahrenheit in all resident bathrooms. There are grab bars for each toilet, bathtub and shower used by residents. The facility smoke detectors and carbon monoxide devices were tested and found to be in working order. Facility has been approved for 6 ambulatory residents. During today's inspection, LPA Singh toured the interior and exterior of the facility. The medications are centrally stored and locked in a closet located in the hallway opposite of the Master bedroom. The smoke and carbon monoxide detectors are operable and tested. There were 4 fully charged fire extinguishers observed LPA Singh observed all cleaning supplies are locked in a cabinet located in the laundry room and underneath the kitchen sink. The sharp objects are stored in a lock box, inside of the pantry located inside of the kitchen. All doors, and passageways are clear from obstruction and were equipped with night lights. There is a fire place located in the family room that is screened and covered with glass. All beds have the required linen and supplies. There was a sufficient amount of clean linen and hygiene items stored in two cabinets located in both hallways. There was appropriate lighting in each room. There are no fire arms or ammunition stored at the facility. Food Service: There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods. Dishes, cups, and utensils were also stored properly. Record Review: LPA requested and reviewed three (3) resident and three (3) staff files. LPA Singh reviewed staff files for current CPR/1st aide certificates, TB results, and required training's. LPA observed the emergency disaster plan, facility sketch, personal rights, and theft and loss policy, PUB 475 complaint poster hung on the wall in the entryway. Administration: LPA Singh did not observe any excluded individuals on the premises at time of visit. The Administrator appears to be on the premises a sufficient number of hours to manage and oversee the business operation. Medical Related Services: Prescriptions and non-prescription PRN medications contain a signed and dated written order from a physician. Medications are centrally locked in the staff office and inaccessible to residents in care. Medications are being administered as prescribed by physician's directions. No deficiencies cited. An exit interview was conducted where this report was provided and discussed with Ms Riley.