Routine inspection·August 22, 2023

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Manzoor Massey, Administrator and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) clients with a current census of (5). Hospice waiver for (2). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Fireplace is adequately screened . LPA observed outdoor pool is empty and enclosed with a locked fence inaccessible to clients in care. Backyard is also secured with latched gates. LPA inspected the kitchen. The refrigerator and freezer are operating in a safe and healthful manner. Hot water temperature is maintained at 106 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of clients in care. Facility has sufficient cups, plates, and utensils for client use. Facility food is stored in a safe and healthful manner. LPA inspected client bedrooms. Bedrooms are equipped with beds, linen, nightstands, chairs, and sufficient lighting. LPA inspected client bathrooms. Bathrooms are operating in a safe and sanitary condition. The hot water temperatures in bathrooms tested between 106 and 108 degrees F. LPA observed the facility is equipped with operating carbon monoxide alarms. Facility has operating telephone service on the premises. Posters such as personal rights, Ombudsman contact, emergency phone numbers are posted in a common area. Sharps, disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to clients in care. Administrator was not able to provide documentation of last fire/emergency drill. Deficiency cited. Client medications are kept in a safe and locked cabinet inaccessible to clients in care. All medication are labeled and administered as prescribed. LPA reviewed (3) staff files reviewed for first aid certifications, fingerprint clearances/exemptions, health screening, and training. All (3) staff files did not have record of required care facility training and/or hours of training. (1) staff did not have the proper background clearance. Deficiency cited. LPA reviewed (3) client records reviewed had admissions agreements, physician's reports, assessments, and personal rights. Deficiencies are being cited and civil penalties accessed during today's visit. An exit interview was conducted, where reports (LIC809/LIC809D/LIC9102) were discussed and a copy of reports with appeal rights was provided to the Administrator at the conclusion of the visit.