Follow-up·August 24, 2024

On 08/24/2024 at 08:45 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a Case Management Visit. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were two (2) staff present, and six (6) residents present. Licensee/Administrator Kristine Mangente was contacted and informed of the visit. Licensee/Administrator Mangente arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Mangente. The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents. The facility has six (6) Hospice Waiver. The current census is six (6) residents. LPA Brown was accompanied by Staff #2 (S2) and Licensee/Administrator Mangente to conduct a Case Management visit, which included, but was not limited to the following: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. ***Continuation in LIC809C *** Moreover, during the tour of the facility, LPA Brown observed multiple bottles of chemicals not locked, and accessible to residents in care. Deficiency will be issued. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 109 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. Furthermore, during the tour of the facility, LPA Brown observed Staff #2 (S2) working at the facility with criminal background clearance but S2 criminal background clearance was not transferred to the facility. Deficiency will be issued and civil penalty will be assessed of $500.00 and will continue to be assessed of $100.00 until corrected. Also, LPA Brown observed Staff #3 (S3) working at the facility without criminal background clearance. Deficiency will be issued and civil penalty will be assessed of $500.00 and will continue to be assessed of $100.00 until corrected. Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. The facility has an administrator present in the facility. LPA Brown did not observed sufficient number of staff to provide care and supervision to the residents in care as no staff scheduled to work the night shift as required for facility with dementia residents. Deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Kristine Mangente.