Routine inspection·November 7, 2024

Licensing Program Analysts (LPAs) Iby Strong and David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Administrator Gilbert Zachay. According to the facility’s license, the facility has a maximum capacity of six clients, of whom all may be non-ambulatory and one of which may be bedridden. LPAs toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to client. Medications were labeled, as required, and stored in locked areas. Water temperature was measured at 120 degrees F. No pools or bodies of water on the premises. Per Gilbert, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Resident records reviewed had required documentation, Resident 1 (R1) did not have a physician report but Gilbert states it was created though not available at this time. Staff records reviewed did not contain one first aid certificate for Staff 2 (S2). One deficiency was cited today for S2 first aid training, and one technical violation was issued for no medical assessment for R1. An exit interview was conducted with Administrator Gilbert Zachay, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22), LIC 809-D and LIC 9201 were provided during the visit.