Routine inspection·September 20, 2023

Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a Required 1- year annual inspection utilizing the full CARE tool. LPA met with Caregiver, Abigail Ndukwe, who informed LPA Administrator is not at the facility. LPA entered the facility and contacted Administrator. Administrator arrived to the facility approximately 25 minutes later. LPA and Administrator discussed the importance of Inspection Authority of Licensing Agency and criminal clearance transfer request. LPA and Administrator conducted a tour of the interior and exterior of the facility. LPA observed the presence of four residents in care, LPA was informed there is no resident in care under hospice services. LPA and Administrator toured four private residents room, one shared resident room, caregiver room, two bathroom, kitchen, office, storage room, backyard and common areas. LPA observed the facility to have 2+ days of perishable and 7+ days of non-perishable food. LPA observed toxins, sharps and medication to be locked and secured in the kitchen. LPA observed the fire extinguisher to last service on 01/11/2023. LPA observed temperature of the facility to be 77*. LPA conducted a file review of 3 out of 4 residents file. LPA was unable to inspect 1 out of 2 personnel files. LPA and Administrator discussed that all over the counter medications are to be approved and ordered by physician. LPA requested a copy LIC500, LIC308 and liability insurance to be emailed to LPA by Friday September 22, 2023 at 5PM. As a result of today's inspection, deficiencies observed. See LIC 809-D. Exit interview. Copy of the report and appeal rights provided.