Routine inspection·December 6, 2024

On 12/06/2024, Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator Iren Creighton. LPA introduced self, stated the purpose of the visit and gained entry to the residence. LPA was informed that there are currently 5 residents in care, two (2) bedridden and (3) non-ambulatory. The facility has 6 bedrooms, 4 bathrooms, kitchen, dining area, living room, office, laundry, attached garage and backyard. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 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 bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 115 degrees Fahrenheit. The facility is equipped with operational smoke detectors, charged fire extinguishers and first aid kit. LPA did not observe an identifiable carbon monoxide detector. A deficiency was cited. Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins and other dangerous items were kept locked and inaccessible to residents. LPA observed a pair of scissors and knives to be in unlocked kitchen drawers. A deficiency was cited. There was a designated storage space for resident/staff files. Medications were observed to be locked and inaccessible to residents. LPA observed two (2) resident files without physician's orders for medication. A deficiency will be cited. There is no swimming pool, firearms 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 residents in care. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, side gate with self-latching handle on the left side of the house that leads into the backyard. Record Review: LPA reviewed staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed two (2) staff without First Aid/CPR certification and three (3) staff without physician's reports and tuberculosis clearance. A deficiency was cited. Five 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 Adminisrator Iren Creighton.