Routine inspection·June 5, 2025

On June 5, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a required annual inspection utilizing the care tool. LPA met with Licensee/Administrator and explained the purpose of the visit. Today's census is 37 residents with zero (0) residents on hospice. Facility is compliance to license. LPA and Licensee conducted a tour of the interior of the facility. Areas toured included but not limited to: six (6) residents room, dining room, activity room, laundry room, shower room, kitchen and the common areas. LPA observed kitchen to be restricted to staff only. LPA was informed that if cook is not present then door will be locked for remainder of time. LPA observed present of two days of perishable and seven days of nonperishable foods. LPA was informed that day of visit, the freezer stopped working. Licensee is actively working on its repairs. LPA observed facility to have ample supply of linens, and hand sanitizers throughout the facility. LPA observed residents room to be free of sharps, toxins and medications. LPA was informed that medications are centrally stored unless stated otherwise by physician order and/or physician's report. File review was conducted for seven (7) resident records and five (5) personnel records. LPA observed resident records to have the required documents. LPA advised Licensee that all documents for each residents should be filed together. LPA observed staff files to be complete. LPA reminded Licensee that all staff are to have their initial 40 hours of training then follow with 20 hours of annual training. Staff who are administering medications are to have additional 24 initial hours of self-administration medication training. Please continue on LIC 809-C.