Routine inspection·February 29, 2024

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with caregiver Lalaine Campbell 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. Such measures include: soap and disposable (one-time use) towels at hand washing stations, and tight-fitting lids on trash cans. Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin observed that S1 has been working at the facility for two years and does not have criminal record clearance associated to the facility. In S1's file, LPA Colvin observed a written request from the Administrator to the Licensing office, dated 2/7/24, requesting to associate S1 to the facility. This request did not include the required information to process the transfer. LPA Colvin additionally observed a criminal background clearance transfer request in S1's file which was also incomplete, as it was missing S1's background clearance number. Deficiency cited. When a facility has staff present who do not have a criminal background clearance transferred to the facility, a civil penalty of $100 a day for every day the person is at the facility is assessed. LPA Colvin will be assessing a $500 civil penalty ($100 a day for 5 days), which is the maximum that can be assessed unless the violation is repeated. Incidental Medical Services: LPA Colvin observed that resident medication is locked in the hallway and inaccessible to 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 106.8 degrees. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives were locked in the kitchen away from residents' reach. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. Due to time constraints, the annual will be continued on a later date. Observations were documented and will be addressed during the annual continuation. An exit interview was conducted with Caregiver Lalaine Campbell and a copy of this report, LIC809D, LIC421BG, and appeal rights were provided.