Routine inspection·October 24, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA initially met with Steve Heydon, Administrator Designee, and explained the reason for the inspection. Administrator, Anita Heydon, arrived at 12:15 pm. Also present was staff, Ram Pratap. LPA observed (2) residents watching television in the common area, (3) residents resting in their rooms, and (1) resident returned to the facility during the inspection. The facility is licensed for (6) residents and has a hospice waiver for (3). There are currently no residents under hospice care. LPA and Administrator Designee toured the interior and exterior of the facility including the common areas, (2) shared resident rooms, (2) private resident rooms, (2) resident bathrooms, kitchen, staff room and garage/locked laundry area. LPA observed the facility to be clean, in good repair and odor-free. There is 2+day perishable and 7+day non-perishable supply of food with additional freezer storage in the garage. Sharps are locked in the kitchen. The bathrooms have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. Locked medications are secured near the kitchen and toxins are locked in the garage and bathroom. The inside temperature measured 70*F. Fire extinguisher was last serviced 5/21/24, and the smoke/monoxide alarms are working. Hot water temperature measured 109*F in the kitchen. There is a complete First Aid kit. There are sufficient linens/towels/paper products/PPE. There is an outside patio table with chairs and an umbrella, and one unlocked exit. There are no pools. The Infection Control and Emergency Disaster Plans were complete and reviewed within the last year. (3) resident files were reviewed/found to be organized and contain current paperwork. Medications were reviewed for (2) residents- orders matched medications being administered. Documentation was current. cont on 809C. 809C-1.. (4) staff files were reviewed. All staff is cleared and associated. Files were organized and complete. Initial and/or ongoing training documentation was filed. Staff has current First Aid/CPR certifications and will ensure all required ongoing training hours are completed by 11/30/24. An approved on-line vendor is used for staff training. Administrator certification #7019616740- exp 7/4/25 posted at the front entrance. LPA requested an updated copy of LIC500, LIC308 and of the current liability insurance by 10/31/24. Obtained updated email address. Administrator to submit documentation of required staff training hours to be completed within the last 12 months, by 11/30/24. There are no deficiencies issued, but there is a Technical Violation being issued. Exit interview with Administrator. Copy of report provided.