Routine inspection·August 28, 2024

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Staff, Revelan Ibera. Licensee, Syeeda Akhter-Rahman 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, toilets, and showers were in working order. The sink in bathroom #2 has a leak. However, the licensee has already contracted an outside source for repairs. 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 106 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 toxic chemicals/poisons accessible to residents. LPA observed chemicals were accessible under the kitchen sink and in the garage. There was a lock on the kitchen cabinet under the sink but it was not locked. Medications were labeled, as required but not locked. A lock was present on the medication closet but it was not locked. The facility has a resident that walks around the facility independently. 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 and readily accessible. Required licensing postings were observed in visible areas of the facility. Continued on an LIC 809C. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. Also, required staff training was not documented. Confidential records were stored in locked areas. Deficiencies were observed or cited during today's annual inspection. Also, Advisory Notes were issued. An exit interview was conducted with the licensee to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.