Routine inspection·March 11, 2025

Licensing Program Analyst (LPA) Sabrina Calzada and Associate Governmental Program Analyst, Vanna Le, arrived unannounced to conduct a required annual. LPA met with caregivers, Taneshea Terri and Trissel Sloley, and stated the reason for the inspection. Administrator, Carmen Ion, arrived at approximately at 9:25 am. LPA observed (2) residents in the common area and (2) residents to be in their rooms at the start of the inspection. There is (1) resident currently under hospice care. LPA and Administrator toured the interior and exterior of the facility including the common areas, (1) private resident bedroom, (2) shared resident bedrooms, (2) resident bathrooms with showers, kitchen, office and garage/laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps in the kitchen, locked toxins in the laundry area and locked medications inside. Inside temperature measured 75*F and hot water measured 126*F in a bathroom. There is a signed posted near each bathroom sink and near the kitchen sink. The fire extinguisher was last serviced on 3/5/2025, and the smoke/monoxide alarms work. Quarterly emergency drills are being conducted- facility will ensure there is a drill conducted on each shift, at least every quarter. There are sufficient towels, linens, blankets and incontinent products. First Aid kit is complete. There are activities/games on site with sufficient indoor/outdoor space. There is (1) unlocked exit gate and patio seating. There are ramps at the front and back entrances with hand rails. There are multiple postings are in the common area. Facility to update Resident Rights poster. (3) resident files were reviewed. Files are organized and have current documentation, including care plans/physician's reports. Medications were reviewed for (1) resident- orders matched medications being administered and documentation is complete. Facility to begin noting the start date on each bubble pack/bottle of medication. (6) staff files were reviewed. Files are complete, organized and contain current training documentation, including First Aid/CPR. RCFE Administrator certificate # 6034379740- exp 3/16/25- renewal documents to be submitted prior to expiration. Plan of Operation has been updated 2/5/25 with updated Dementia Care regulations. There were no deficiencies observed. Exit interview. Copy of report provided.