Routine inspection·June 22, 2023

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 6/22/23 to conduct a Required-1 Year Inspection utilizing the CARE inspection tool. LPA met with Licensee and explained the purpose of the visit . Inspection completed with Licensee and Administrator. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home was found to be clear, safe and sanitary. LPA advised that the fire door magnet mechanism be inspected for proper operation, the fire extinguisher be inspected as due soon, all resident rooms ensure emergency exits are clear of obstacles. LPA reviewed 6 resident files and 2 staff files. LPA advised all medication orders be signed (electronic or written), if medications are to be here is a written order, that the medication administration system does not use pre-poured medications and ,bed rail orders are on file. 1 of 2 staff, S1, was found to be out of compliance with annual training compliance LPA received a copy of liability insurance. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with licensee . Copy of this report and appeal rights provided.