Routine inspection·April 24, 2024

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Anahit Mesropyan and informed her of the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 136.5 degrees. Deficiency cited. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. Knives are kept locked in a drawer in the kitchen and away from resident reach. Operational Requirements: The facility has a licensed capacity of 6 non-ambulatory residents, one of which may be bedridden. Facility has a hospice waiver for 6 residents. LPA Colvin observed the facility to be operating within these parameters. Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator present at the facility and that their Administrator Certificate is current. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs. Resident Records: LPA Colvin reviewed the files for all 3 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. All resident files contained required documents for residents' care. Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. Planned Activities: LPA Colvin confirmed that the facility provides activities for residents to engage in. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and is conducting regular Emergency Disaster Drills. An exit interview was conducted with Administrator/Licensee Anahit Mesropyan and a copy of this report, LIC809D, and appeal rights were provided.