Routine inspection·November 3, 2023

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Elizabeth Mahan , Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (20) with a current census of (19). 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 were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured 105 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has carbon monoxide alarms and telephone service. 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, rights of resident counsel, disaster evacuation plan and emergency telephone numbers. Yards/Outside: Outdoor passageways are free of obstruction. The facility has no bodies of water. The facility is enclosed by a fence 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. Soaps 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 at the facility have criminal record clearances or exemptions through the Department. Record Review: LPA reviewed staff files at random. Staff #1 (S1) did not have record of medication training on file and staff #2 (S2) did not have record of health screening results and first aid/CPR training on file. LPA reviewed resident files at random. Resident #1 (R1) did not have a current annual medical assessment on file, last medical assessment was conducted on 5/18/22. Medical Related Services : All medication is centrally stored and kept in a locked cabinet inaccessible to residents in care. Based on observations and record review, deficiencies were cited during today's visit and plan of correction was discussed with the Administrator at the conclusion of the visit. An exit interview was conducted where the licensing reports were discussed, and copies provided to the Administrator at the conclusion of the visit.