Routine inspection·April 28, 2025

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility and conducted the visit with Licensee, Donna Abitria. LPA, accompanied by licensee, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. However, there was a hole in the exterior wall to room #5 but the inside of the wall was sealed. Licensee scheduled repairs during the visit to be completed. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was 78 degrees F. Hot water temperature at taps accessible to residents measured at 112 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. Facility has a pool, which was gated and locked, made inaccessible to residents. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Continued on an LIC 809C. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. However, the licensee/caregiver did not have proof of the annual required training but confirmed they completed the course and will obtain proof and submit it to the department. In addition, the disaster drill was not conducted quarterly, last drill on file was 01/14/25. The Emergency Disaster Plan did not reflect annual training. Confidential records were stored in locked areas. Liability Insurance expired on 04/11/25, licensee stated they are in the process of obtaining a new insurance company and will provide proof within in 2 weeks. The facility does not have a current administrator on file. Licensee stated they hired a new administrator but needed to complete the documentation. Licensee added a staff room in the family room area but didn't update the facility sketch. Licensee was made aware of the requirements for an updated Plan of Operation to include new Dementia laws. Deficiencies were observed during today's annual inspection. Also, Technical Advisories were issued. An exit interview was conducted with Licensee, Donna Abitria to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.