Routine inspection·July 17, 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, Josie Marty . Administrator, Irma Laconsay 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 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 resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 111 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, and stored in locked areas. 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 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. LPA reviewed multiple staff and resident records/files. Resident records did not reflect current ambulatory status. Residents #1, #2 #4 are unable to reposition on their own. Administrator confirmed the staff assist with repositioning as the residents are unable. Continued on an LIC 812C. The facility does not have a bedridden fire clearance. Resident #5 is not on hospice but has full bed rails. The administrator stated R5 is a fall risk and there was concern the resident would fall out of bed. Administrator was made aware bed rails may not be used as a restraint but for mobility use. Administrator stated they will remove the full bed rail. Confidential records were stored in locked areas. LPA was away from the facility for approximately one hour between 1:20pm and 2:20pm. Deficiencies were observed and cited during today's annual inspection. A civil penalty was assessed for a fire clearance violation. An exit interview was conducted with Administrator, Irma Laconsay to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.