Routine inspection·February 8, 2024

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Mary Phetsanghane. Administrator Joseph Alvela Jr. arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six non-ambulatory residents, age 60 and over, 1 of which may be bedridden. The facility has a hospice waiver for 6. During today’s inspection, there were a total of 5 residents in care, and per medical records, all are non-ambulatory. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by the Administrator, 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. Client 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 client activities. The facility’s ambient internal temperature was 74 F. Hot water temperature at taps accessible to clients were all compliant: Bathroom #1 sink was 114.9 F, Bathroom #2 sink was 115.8 F and Bathroom #3 sink, which had two sinks, were 112 F and 110.7 F. No pools or bodies of water were observed on the premises. Per Administrator Joseph Alvela Jr., no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and residents. LPA reviewed staff and resident records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. The Administrator also presented proof of current/active business liability insurance. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Joseph Alvela Jr, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.