Follow-up·December 14, 2022

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required quarterly case management inspection. LPA met Mele "Mary" Tonga, caregiver, initially and then Vera Okyere, Administrator and explained purpose of inspection. LPA observed all (5) residents to be in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (4). Currently, there are (0) residents on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, wore a surgical mask and was screened per Covid-19 precautionary measures upon entering the facility. During today's inspection, LPA observed copy of Stipulation entered on 8/25/22 to be posted in a conspicuous place at the facility. LPA reviewed the binder with documentation of monthly training for all staff to have been completed from 9/6/22- 12/9/22. Different medication topics were discussed/presented each month as required. In addition, LPA observed completed training for the Administrator regarding medication administration and storage and resident personal rights. Administrator confirmed there is no longer a portion of the facility being used as a room and board. Administrator to schedule N95 FIT testing for self/staff as required. Administrator advised the Department will conduct a subsequent quarterly visit on/around March 2023. There are no deficiencies issued on this report. Exit interview. Copy of report provided to Administrator.