Routine inspection·November 17, 2023

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Edna Santo Domingo. Administrator Julia Goker arrived during the visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 1 of which may be bedridden in bedroom 4. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 5 non-ambulatory residents. The facility does not have a clearance for delayed egress or secured perimeter and LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Julia Goker and their certificate is pending as of 6/15/2023. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. According to the Administrator, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 115.0 degrees Fahrenheit in a common bathroom and 111.0 degrees Fahrenheit in a private resident bathroom. The facility’s internal temperature was measured at 71 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Continued on LIC809-C page... Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. No deficiencies were cited on today's date. An exit interview was conducted with Administrator Julia Goker, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).