Routine inspection·September 4, 2024

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/4/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was unavailable to assist. 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 is clean and residents appear to have their care needs met. LPA reviewed 6 resident files. R1 and R1 need hospice care plans and R5 and R6 need updated Needs and Services Plans LPA reviewed 2 staff files. S1 needs 1st aid training, S1 and S2 need training for restricted conditions present. S2's file is still being completed. Licensee will submit proof of liability insurance and Admin certificate. 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. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with designee. Copy of this report and appeal rights provided.