Routine inspection·January 25, 2024

On 01/25/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with caregiver, Crystal Taylor and introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in the facility and 2 residents in day program. The facility has 8 resident bedrooms with bathrooms included, 1 staff office with bathroom, kitchen, dining area, reception area, and shaded patio. LPA completed a walk through of facility and of review of records. Medication not audited due to timing. Physical Plant: The facility is approved for 18 ambulatory which 18 can also be nonambulatory and hospice waiver increased from 6 to 12. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathroom; bathroom was clean and appliances were found functional. Water temperatures tested at 110 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. There are no guns or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service : Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, a side gate with self-latching handle on the front side of the facility that leads into the back patio. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed 3 resident files for admission agreements, updated physician reports, and needs and services plans. LPA discovered the facility is providing care for two (2) bedridden residents which are not approved per the facility's license. Deficiency issued with civil penalty. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. The facility last conducted a fire drill on 12/04/2023. LPA observed that the Emergency Disaster Plan does not have a signature and date. Deficiency issued. Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC412IM and appeal rights were discussed and copies were provided to Grabriella Taylor.