Routine inspection·February 28, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Marjorie Reboja, Administrator, and explained purpose of inspection. LPA observed (4) residents present in the facility. The facility is licensed for (5) non-ambulatory residents and has a hospice waiver for (2). Currently, there are no residents on hospice. LPA and Administrator toured the interior and exterior of the facility including the common areas, (3) resident bedrooms, (2) full bathrooms, kitchen, and locked laundry area on the first floor. The second floor of the facility is used by the Administrator. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels, soap and trash can. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps and medications in the kitchen, and locked toxins in the laundry area. Fire extinguisher was last serviced 8/25/23 and the smoke monoxide alarms are working. There are multiple Covid posters as well as other required postings in the common area. Facility conducts quarterly fire drills. There are sufficient linens/towels/paper products/PPE. Inside temperature measured 71*F and hot water measured 108*F in the kitchen. LPA reviewed (3) resident binders and found (2) care plans and (1) physician's report to need updating. Medications were reviewed for (2) residents. A technical advisory note is issued. LPA reviewed (3) staff binders. All staff are missing current certification in First Aid/CPR. Administrator certificate #6010895740 is pending renewal and #701034570 (exp 5/21/25) are posted. All staff is cleared and associated. There is (1) unlocked gate from the inside back patio. There are no bodies of water/pool. LPA reviewed/approved the Infection Control Plan. Emergency Disaster Plan is complete. LPA obtained an updated copy of current liability insurance, and requested LIC500 and LIC308 be submitted to the Department by 3/7/24. LPA to email some additional sample forms. There are (3) deficiencies issued on the 809D pages. Exit interview with Administrator. Copy of report and appeal rights provided.