Pre-licensing visit·December 4, 2024

On 12/4/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the pre-licensing inspection tool. LPA met with Applicant who is also the current Administrator of the facility and explained the purpose of the visit. There are five residents in care with zero residents on hospice services. During today's inspection, LPA and Applicants conducted a tour of the interior of the facility. Areas toured included but not limited to: six residents rooms, two bathroom, kitchen, garage and the common areas. LPA observed facility to have sharps and toxins locked and secured. LPA observed facility to have the required posters in the common area. LPA observed Emergency Disaster Supply Kit to be present in the storage closet. LPA was informed there are currently two residents in care that are bedridden. Current facility is licensed for one bedridden in Bedroom #6. Pending facility is approved for six non-ambulatory. LPA informed Applicants that at this time facility is out of fire clearance compliance. LPA explained that residents who are non-ambulatory who then became bedridden can be acceptable with the exception that resident is on hospice services. LPA informed Applicant to submit a new LIC 200 with the capacity change of six non-ambulatory to five non-ambulatory and one bedridden along with a new facility sketch. LPA informed Applicant if change is not made, current facility may be assessed with a immediate $500 civil penalty and with the necessity of resident relocation. §1569.72 Residents requiring skilled nursing or intermediate care; bedridden residents (b)(1) For the purposes of this section, "bedridden" means requiring assistance in turning and repositioning in bed or being unable to independently transfer to and from bed, except in a facility with appropriate and sufficient care staff, mechanical devices, if necessary, and safety precautions, as determined by the director in regulations. Correction is needed prior to inspection approval. Exit interview conducted.