Routine inspection·November 6, 2023

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Iren Creighton, Facility Representative, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (6). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms are equipped with grab rails and operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 112 degrees F. Resident’s bedrooms have sufficient lighting and bedroom furniture is in good repair. Facility has operating carbon monoxide alarms and telephone service. Facility fireplace is adequately screened. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, disaster evacuation plan and emergency telephone numbers. Yards/Outside: Outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility is enclosed with self-latching gates. Outdoor shaded area is sufficient for resident activities. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Disinfectants and other cleaning solutions were kept locked and stored away from food areas. Care & Supervision : Facility has 24-hour/7 days a week care staff. Staff working have criminal record clearances or exemptions through the Department. Record Review: LPA reviewed (3) resident files and (3) staff files. Licensee did not maintain verification of staff #1 (S1) complete health screening results. Resident (R1) and resident #2 (R2) preplacement appraisals were observed incomplete. Licensee did not maintain proof of R1's complete health screening results. LPA observed facility's last emergency drill was conducted in July 2019. Facility did not maintain verification of liability insurance on file for licensing review. Medical Related Services : All medication is centrally stored, administered as prescribed and kept in a locked closet, inaccessible to residents in care. Deficiencies were cited during today's visit and a plan of correction was discussed with facility representative, Iren Creighton. An exit interview was conducted and copies of the licensing reports with appeal rights were provided to the facility representative at the conclusion of the visit.