Routine inspection·March 20, 2024

Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual review. LPA was greeted by Administrator, Amelia Perlow and explained the purpose of the visit. A tour of the facility was conducted inside and out. Present at the facility were two clients and one additional staff was available. The facility is a four (4) bedroom four (4) bathroom one story home. During the tour the following was observed: Clients bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible to clients. Hot water was tested at 118.5 degrees Fahrenheit. Backyard area is free from obstructions. Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional. Care & Supervision : Facility has sufficient care staff employed. Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. The following deficiency was observed: The Administrator could not recall nor have record of the last emergency drill conducted. LPA advised Administrator drills are to be conducted quarterly. Deficiency cited. Record Review and Client/Staff Files: LPA reviewed current staff and all staff have has Criminal Background Clearance and trainings are current, however the following deficiency was observed: -The facility staff did not have current CPR/First Aid certification. Certification for all staff expired on 6/7/2023. Deficiency cited. Client records were reviewed and contained required documents that included Admission Agreement, Pre-Appraisal, current Physician's Report. Medication Review: LPA reviewed medication and medications appear to be dispensed according to physician's orders, however the following deficiency was observed: - The facility did not have an updated medication record keeping system of medication dosages given to residents. Administrator stated they are in the process of updating the system. Deficiency cited. An exit interview was conducted and a copy of this report along with LIC 809D, LIC811, and Appeals Rights was provided to Administrator, Amelia Perlow.