Routine inspection·October 4, 2023

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Eva Tawfik, Executive Director, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). Licensed capacity is (110) with a current census of (89). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected all six (6) resident cottages inside and out. Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient indoor and outdoor activity space for residents in care. Activities are posted in a common area of each cottage. All cottages are enclosed with self-latching gates. Facility has no bodies of water. LPA inspected the kitchen. Facility has sufficient non-perishable and perishable food for the number of residents in care. Menus are posted in various areas of the facility. Facility food is stored in a safe and healthful manner. Sharps are stored and kept locked and inaccessible to residents. LPA inspected resident bedrooms. Bedrooms are equipped with beds, bed linen, chairs, nightstands, storage space and sufficient lighting. LPA inspected resident bathrooms. Bathrooms were equipped with grab rails and operating bathroom equipment. The hot water in four (4) bathrooms tested below regulation requirement. Bathrooms in rooms 202, 203, 404, 506 tested between 86 to 96 degrees F. LPA observed the facility is equipped with operating carbon monoxide alarms and telephone service. Facility has a complete first aid kit. Posters such as personal rights, Ombudsman Poster, the disaster plan and emergency numbers were posted in a common area. LPA reviewed six (6) client medications and centrally stored medication logs. All medications are labeled and administered as prescribed. LPA reviewed six (6) staff files for criminal record clearances, trainings, and health screenings. Employed staff 1 (S1) did not have a criminal record clearance. LPA reviewed six (6) resident records for admissions agreements, physician's report, pre-admission appraisals and emergency contacts. All records had the required documentation. Deficiencies were cited during today's visit and a plan of correction was discussed with Executive Director T awfik. Copies of reports (LIC809/809-D/LIC9102) with appeal rights were provided to the Executive Director at the conclusion of the visit.