Routine inspection·December 4, 2024

Licensing Program Analyst (LPA) Talwinder Bains arrived on 12/04/24 to conduct the annual inspection. LPA met with Staff, Sevrena Miller and explained the purpose of today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed two residents (2) and two staff files (2). Staff files have required paperwork. LPA found missing documents in residents (R1,R2) files and citation has been issued as indicated on LIC809D. LPA and staff 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 118 degrees F, which is within the regulation range of 105-120 degree. Fire extinguisher was serviced on 03/15/24 and was ready for emergency use. LPA audit medications for residents, R1,R2. During record review, LPA found multiple medications management issues for R2 and citation has been issued as indicated on LIC809D. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 12/31/24 . Deficiencies are cited on LIC809D per Title 22 Regulations. Exit interview conducted. Appeal Rights and copy of this report left at facility.