Routine inspection·October 4, 2023

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Mariana "Mimi" Musca, caregiver, and stated reason for the inspection. Mariana contacted the Administrator, Adina, by phone, who arrived at approximately 2:00 pm. LPA was advised that (2) of (6) residents were out of the community; (1) returned during the inspection. (1) resident is currently under hospice care. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). LPA and Administrator toured the interior and exterior of the facility including the common areas, (6) resident bedrooms with private bath, (2) full bathrooms, kitchen, staff rooms and garage/locked laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps, toxins and medications in the kitchen. There are locked medications in the refrigerator. LPA observed the inside temperature to be 79*F. Fire extinguisher was last serviced 8/21/23. Hot water temperature measured 110*F in the kitchen. First Aid kit on site as well as sufficient paper products, including PPE. All required postings are posted. LPA reviewed the Infection Control Plan (LIC9282) and additional pages, that were last updated on 5/23/23 and found it to be very comprehensive. LPA observed (1) unlocked gate from the inside back patio with covered patio seating. There are no pools or bodies of water. LPA observed copy of RCFE Administrator certificate # 6004705740- exp 11/2/23- renewal documentation to be submitted this month. LPA reviewed (3) resident files and found them to contain current/complete documentation. Meds were reviewed for (1) resident and orders matched meds being administered. Documentation is current also. LPA reviewed all staff files - all staff have current First Aid/CPR certification and have completed recent annual training for (40) hours. LPA requested an updated copy of LIC500, LIC308 and current liability insurance today by 10/11/23. There are no deficiencies issued during today's inspection. Exit interview with Administrator. Copy of report provided.