Routine inspection·July 18, 2023

On 07/18/23 at 8:22 AM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA was greeted and granted entrance by Licensee, Brittney Smith. LPA introduced self and stated the purpose of the visit. LPA observed that there are currently 3 residents in the facility. Licensee provided LPA with a tour of the facility. The facility has 3 bedrooms, 2 bathrooms, 1 staff office/bedroom, a kitchen, dining area, living room, attached garage, and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is not clean, safe, and sanitary. LPA observed the living room with storage boxes, dirty floors and the back yard with dog feces and dog hair. Deficiency issued. The facility is not free of obstructions to indoor and outdoor passageways. LPA observed bricks, poles, building materials on side gate and driveway. Deficiency issued. The facility is maintained at a 76 degrees fahrenheit temperature. LPA inspected residents bedrooms; they are equipped with furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA noticed a malodor of urine in bedroom #3 with 2 residents inside laying down. Deficiency issued. LPA also observed cameras in residents room with audio confirmation per Licensee's statement. Deficiency issued. There is an adequate supply of linens and blankets stored in a closet in the main hallway of the residence. LPA inspected residents bathrooms; bathroom was clean and appliances were operating appropriately. LPA observed that the bathroom trash cans do not have a tight-fitting cover. Deficiency issued. LPA also observed PRN hemorrhoid ointment found in a cabinet beneath hallway bathroom sink. Technical violation issued. LPA tested the water temperature in the kitchen faucet, which tested at 110 degrees fahrenheit within regulation. The facility is equipped with operating fire extinguisher, smoke detectors and carbon monoxide alarm. Posters such as; the personal rights, CCL complaint poster, Ombudsman and the emergency disaster plan were posted in a common area. Cleaning supplies, and toxins were kept locked. LPA observed knives found in drawer and drying rack and a blade in a drawer made accessible to residents. Deficiency issued. There was a designated locked storage space for client/staff files, first aid kit and medication. The facility has a working phone. There are no pools, bodies of water, firearms or ammunition. Yards/Outside: One shaded patio furniture for outdoor seating observed. Side gate with self-latching handle on the right side of the house that leads into the backyard. Dogs inside kennels also found in back yard. Food Service : The facility has 7 days of non-perishable food supply and an insufficient supply of 2 days of perishable food. Deficiency issued. LPA observed 24 containers of expired Glucerna found in pantry since 02/01/23. Deficiency issued. LPA also observed the refrigerator, pantry, stove, and stove fan unsanitary and not clean. Deficiency issued. Dishes, cups, and utensils were stored properly. Record Review: LPA reviewed the Administrator's file and 3 Staff files. Staff files are incomplete and missing First Aid/CPR certification. Deficiency issued. Staff training records missing. Deficiency issued. LPA also reviewed residents files and observed that the physicians report was missing. Deficiency issued. Technical violation and deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and appeal rights were discussed and copies were provided to Licensee, Brittney Smith.