Routine inspection·November 18, 2024

Licensing Program Analysts (LPAs) Rebecca Ruiz and Arian Golbakhsh conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPAs were greeted by, identified themselves to, and explained the purpose of the visit with Caregiver Edna Sto 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 room #4. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 6 residents, 1 ambulatory and 5 non-ambulatory. The Administrator for the facility is Julia Goker and their certificate was valid and current. During today’s visit, LPAs 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 on the premises. LPAs did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 107.4 degrees Fahrenheit in the kitchen sink and 110.5 degrees Fahrenheit in a private resident bathroom. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPAs observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Julia Goker, no firearms or weapons are stored on the premises. LPAs also observed locked storage for resident and staff files. LPAs observed four resident medication bottles placed upon a desk at the main entry and were not secured. Administrator Julia Goker removed the bottles and secured them in the medication cabinet during the visit. Resident medications are stored in their original container and labelled. LPAs observed a minimum of 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 38 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. Continued on LIC809-C page… LPAs observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. 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. LPAs 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. LPAs 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. The Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. The following deficiency was cited for unsecured medications and noted on the attached LIC809-D page. Additionally, a technical violation regarding physician orders was issued and noted on an LIC9102TV form. An exit interview was conducted with Administrator Julia Goker, whose signature below confirms receipt of a copy of this report, the LIC9102TV, and the Licensee Appeal Rights (LIC9058 3/22).