Routine inspection·August 12, 2025

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, Revelyn Ibera . Licensee, Mohammad Rahman and Administrator, Syeeda Seli Akhter-Rahman. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was sanitary, but needs repair. The fridge and freezer had dead insects and debris. Foods were not labeled and dated. The hot water for the sink in restroom #1 is not working, the shower mat was molded, the shower needs repair as far as the walls and crevices. Restroom #2's ceiling fan is making a loud noise and the shower walls and crevices needs to be repaired. Licensee was advised an updated dementia plan was needed along with an addendum to the plan of operation to include video surveillance. Disaster drills are being conducted but not documented correctly. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and toilets, and showers were in working order. However, the sliding door screens are not flush to the frames/bases, all need to be replaced or repaired. There were 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 110 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, but not stored in locked areas. There was insulin and suppositories in the fridge, and the garage had medications belonging to a caregiver, not locked. The licensee explained the insulin was in an unidentified package, made unknown it was insulin and is not being used. Also, the suppositories are not being used. The licensee explained the residents are monitored and do not enter the kitchen area, removing any immediate threat. LPA was able to confirm the medications were not noticeable and had to be pointed out by staff. Also, there were expired medications belonging to residents that no longer resided in the facility but the cabinet was locked. No pools or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was incomplete. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files did not contain required documents. The licensee explained the residents and still working with the families to complete the required documentation. Confidential records were stored in locked areas. The licensee requested to increase their bedridden status. LPA printed the application and assisted with completion. Deficiencies were observed or cited during today's annual inspection, along with Technical Advisories. An exit interview was conducted with Licensee, Mohammad Rahman to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.