Routine inspection·February 26, 2025

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Jemela Magulod. LPA spoke with House Manager Lauren DeLancey via telephone. During today's visit, LPA briefly toured the facility, reviewed facility records, and observed residents in care. The facility is licensed for a maximum capacity of 6 residents, 4 of which may be ambulatory and 2 of which may be non-ambulatory in bedroom #5. Review of all residents' medical assessment and appraisal records revealed that 5 of 6 residents (R2, R3, R4, R5, and R6) had a diagnosis of major neuro-cognitive disorder and 5 of 6 residents (R1, R2, R3, R5, and R6) required the use of mechanical aid devices to ambulate, such as walkers and wheelchairs. [Caregiver was provided with an LIC811 Confidential Names List to identify residents] Interviews with facility staff revealed that R4 and R5 are bedridden and unable to get out of bed. LPA confirmed residents' use of mechanical aids via interviews with staff. The diagnosis of major neuro-cognitive disorder and the use of mechanical aids to ambulate revealed that R1, R2, R3, and R6 are non-ambulatory and R4 and R5 are bedridden, which is violation of the facility's fire clearance approved on 3/11/2024. The following deficiency for fire clearance is noted on the attached LIC809-D page. Additionally, an immediate civil penalty in the amount of $500 is assessed and noted on the LIC421IM form. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. An exit interview was conducted with Caregiver Jemela Magulod , whose signature below confirms receipt of a copy of this report, the LIC421IM, LIC811, and the Licensee Appeal Rights (LIC9058 3/22).