Routine inspection·October 17, 2024

On 10/17/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Resident Care Coordinator and explained the purpose of the visit. Facility has six residents in care with two on hospice services. Facility is currently licensed for six non-ambulatory with hospice waiver for six. During today's visit, LPA and Assistant Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: residents bedrooms, bathroom, kitchen, backyard and the common areas. LPA observed the sharps and toxins to be locked and inaccessible to residents in care. LPA observed medications to be locked and secure in the staff office. LPA observed facility to have two days of perishable and seven days of nonperishable foods. File review conducted for six resident records and four personnel records. LPA observed personnel files to have the required documents needs on file. Additionally, LPA reviewed facility's quarterly Fire Drill, Infection Control Plan and Emergency Disaster Plan. CARE tool completed with Resident Care Coordinator and found facility to be in substantial compliance. AS a result of today's inspection, no deficiencies observed. Exit interview conducted and a copy of the report was provided.