Post-licensing visit·February 13, 2025

On 02/13/24 at 8:42 AM, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to conduct a post-licensing inspection. LPA Lee arrived met with administrator Cleopatra Gardier and explained the purpose of the visit. Administrator assisted with today’s visit. There are currently seven (7) residents currently living at the facility. LPA toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPA observed the kitchen, bedrooms, bathrooms, and common areas. LPA observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed the rooms to be clean and organized with comfortable furnishings. The hot water temperature was measured at 116.3 Fahrenheit. The temperature inside the facility measured at 75 degrees Fahrenheit which was within the required range of 68-85 degrees Fahrenheit. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. LPA observed the following posted in the entrance of the facility. See Something Say Something poster, Ombudsman poster, Reporting Requirements Resident Personal Rights, Evacuation Routes and facility license was all posted as required. LPA reviewed 4 out of 7 resident files and 2 staff files. LPA confirmed that residents’ files have the required documents. However, based on resident record review and observation it was learned that there is a resident who is bedridden; however, the facility is not fire clear for bedridden residents. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. As a result of this post-licensing visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.