Routine inspection·October 28, 2024

On 10/28/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Resident Care Manager (RCM), Iezza Doctolero who was informed of the purpose of the visit. LPA toured the facility’s interior and exterior with RCM Doctolero. The facility is made up of four (4) villas, three (3) of which are designated for assisted living/memory care and one (1) currently occupied by staff. The facility is licensed to care for 29 non-ambulatory residents of which seven (7) may be bedridden. The facility also has an approved hospice waiver for 15 residents and LPA was informed seven (7) residents are currently receiving hospice services at the facility. During the tour, RCM Doctolero tested one of the smoke alarms/carbon monoxide detectors in each villa and LPA observed them to be operational. LPA also observed charged fire extinguishers mounted in each villa, which were last serviced on 1/22/2024. LPA toured the kitchen and observed the facility met Departmental requirements for a two-day supply of perishable foods and seven-day supply of non-perishable food items. Knives and sharp instruments were secured in a locked kitchen drawer. Medications were secured in a locked medication cart, only accessible to authorized personnel such as medication technicians. Cleaning solutions and disinfectants are secured in the locked laundry room, inaccessible to the residents in care. Indoor and outdoor passageways are free of obstruction. Outside shaded seating is available for the residents. LPA reviewed random resident and staff files. Resident files reviewed had signed admission agreement and updated physician's reports. Staff files reviewed had a valid first aid/CPR certification. Staff present have a criminal record clearance and are associated with the facility. LPA reviewed the facility's activity calendar noting there are several activities and outings available for resident leisure. Long Term Care Ombudsman's contact information, complaint procedures, residents' rights, and emergency contact information are visibly posted in each villa. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted where a copy of this report was reviewed and provided to RCM Doctolero.