Routine inspection·April 4, 2025

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a comprehensive annual inspection. LPA met with Administrator, Ngina Smith, and discussed the purpose for the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (5). LPA conducted a general inspection of facility, which included, but was not limited to, the following: Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor activity space, supplies, and games for residents. Outdoor activity space is enclosed with a latching gate. The facility is maintained at a comfortable temperature of 74 degrees F. Resident bedrooms were furnished with beds, night stands, chairs, bed linen and lighting. Resident bathroom equipment were operating properly and bathrooms were equipped with grab rails and slip mats. The hot water temperatures in the bathrooms measured at 112 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms, fully charged fire extinguisher, laundry equipment, and telephone service. Sharps and cleaning solutions are kept in a locked cabinet. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, evacuation plan and emergency telephone numbers. The facility staff schedule reflects 24 hours a day, 7 days a week staff coverage. The facility has a designated area where resident files are stored. Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. Cups and plates were sufficient for number of residents in care. The facility’s refrigerator and freezer were operating properly. Health Related Services: The facility maintains record of resident’s medications and medications were centrally stored in a locked cabinet. **continued on next page** Record Review : The facility has a disaster plan and infection control plan for review. The last emergency drill conducted with staff was on 03/27/25. Resident files were reviewed for admissions agreements, physician’s reports, appraisals, emergency contact list, and care plans. Staff files were reviewed for CPR/first aid and job related training, criminal records clearances/exemptions, personnel job history, and health screenings. No deficiencies were issues and advisories were provided during today's visit. An exit interview was conducted were this report was discussed and copy provided to Administrator Smith at the conclusion of the visit.