Routine inspection·February 7, 2025

Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Caregiver, Donna Norton and introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in care who are in the facility. LPA telephone called the Licensee, Teresa Baddeley and informed her about the purpose of the visit. The facility has 3 resident bedrooms, 1 staff bedroom, 2 bathrooms, kitchen, dining area, living room, family room, laundry room, attached garage, and backyard. LPA completed a walk through of facility, and review of records. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). 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 observed a resident occupying a staff bedroom without fire clearance approval. Deficiency issued. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 120 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the ombudsman, administrator certificate and license were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets 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 bodies of water, guns or ammunition in the facility. 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 right side of the house that leads into the backyard, and a attached garage used for storage. All outdoor pathways were free of obstructions. Record Review: LPA reviewed 3 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed personnel and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed no health screening and TB for 1 caregiver. Deficiency issued. LPA observed a second caregiver arrive and assist residents without background clearance. LPA interviewed caregiver and stated that they had already worked 3 days prior. Deficiency with civil penalty issued. LPA reviewed the facility's insurance coverage, emergency disaster plan, infection control plan and emergency drills. LPA observed that the Infection Control Plan was not reviewed/updated annually. Technical violation issued. LPA observed that the Emergency Disaster Plan was not reviewed/updated annually. Technical violation issued. Deficiencies, two technical violations and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421BG and appeal rights were discussed and copies were provided to Caregiver, Donna Norton.