Routine inspection·May 9, 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 Staff, Petra Galindez. The Licensee, Fahima Nazreen and Administrator, Raushon Ahmed arrived during the visit. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. 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. Hot water temperature at taps accessible to residents were all compliant and measured at 115 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. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and residents. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. Confidential records were stored in locked areas. Resident #4 (R4) has a wound on the back of their neck. R4 was laying in bed with a sweatshirt that was cut in half up the back of the sweatshirt and draped across the front of R4. LPA explained residents should be accorded dignity and wear clothing in good condition. Continued on an LIC 809C. Administrator added it was easier for staff to care for the wound by the sweatshirt being cut open, making the wound accessible for staff. In addition, staff were opening resident bedroom doors without knocking. LPA advised and observed staff enter without knocking after being advised of resident personal rights. Staff were interviewed and unable to answer some of LPA's questions. The administrator was advised vendor training is now required for staff regarding annual training. Deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator, Raushon Ahmed and Licensee, Fahima Nazreen and a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.