Routine inspection·July 23, 2024

Licensing Program Analyst (LPA) Talwinder Bains arrived on 07/23/24 to conduct the annual inspection. LPA met with Assistant Administrator, Jacob Bostanchyan (Jacob) and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed two (2) residents and two (2) staff files and found all required documents in residents files but missing CPR/FIRST AID certification in staff, S1s file and citation has been issued as indicated on LIC809-D. LPA and Jacob toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Hot water temperature was observed to be 109 degrees F, which is within the regulation range of 105-120 degree. Inside temperature was 76 degree F. Facility was clean and well organized. All required postings were observed. Facility is conducting quarterly fire and disaster drill as required. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 08/05/24. LPA reviewed medications of two (2) residents (R1,R2) comparing with physician orders and issues were observed with R1s medications management. LPA observed that facility's only Fire Extinguisher was last serviced on 10/19/2022. Deficiencies were observed and cited per Title 22 Regulations during this visit as listed on LIC809-D. Exit interview conducted ,appeal rights and copy of this report was provided to Jacob.