Routine inspection·August 21, 2024

On 8/21/24 Licensing Program Analyst's (LPAs) Valerie Flores, Ferrer Sabarias, and Andrei Castillo conducted an unannounced one (1) year required visit. LPA's were granted entry by caregiver, Tinisha Sherley, who was informed of the purpose of visit. At the time of the visit there were one (1) staff, and four (4) residents present. Staff present was observed to have obtained proper fingerprint clearance and associated to the facility. LPA's observed the following during today's visit: LPA's conducted a tour of the facility with staff member, Tinisha Sherley. The physical plant contained (4) four resident bedrooms and two and a half (2.5) bathrooms. The common nook area appeared to have live-in staff. Per facility sketch, facility should not attain any residents or staff to reside in that common area. LPA Flores requested the Plan of Operation for the facility to which the on-site caregiver was unable to locate. The facility has a dining room, kitchen, living room, and a gated backyard. Indoor and outdoor passageways were free of obstruction. There were no bodies of water located on the property. The facility has more than a two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. Water temperature measured at 120.4-degree Fahrenheit meeting within the required limits. Dishes and utensils were in sufficient supply and in good repair. Knives and sharp items are located in the kitchen in a locked cabinet. Resident bedrooms had the required bedding, furniture, and lighting. Disinfectants and cleaning solutions were secured in a locked cabinet in the kitchen. Centrally stored medication was located in a locked cabinet in the kitchen. The smoke and carbon monoxide detectors were tested and were observed to be operable. LPA's observed charged fire extinguishers mounted in the living room. Staff files reviewed have a criminal record clearance and valid first aid/CPR certification. Resident files included but are not limited to signed admission agreements, appraisals, and needs and service plan. Per resident files reviewed, facility maintains three (3) out of four (4) residents that are under the age of 60, exceeding the Departments limitation of acceptance of residents under the age of 60. Facility sketch, personal rights, and emergency disaster plan is posted on a wall in the hallway near the entrance. According to caregiver, Tinisha, there are no firearms or ammunition on the premises. During today's visit, deficiencies and technical violations were cited and a plan of correction was discussed. An exit interview was conducted, and a copy of this report was reviewed and provided to Caregiver, Tinisha.