Routine inspection·March 12, 2025

On 3/12/2025 at 09:40am, Licensing Program Analysts (LPA) Haner-Tomasko and De Leon arrived to conducted a one year annual visit to the facility above. LPA met with Backup Administrator Michelle Latham and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility is a 6 bedroom and 4-bathroom home currently occupying 8 resident, employs 5 staff and 2 Administrators. One common area restroom, a jack and jill style restroom between two of the bedrooms and 2 private in suite bathrooms. The kitchen is clean, safe and sanitary. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. The facility has smoke and carbon monoxide detectors. Facility is well lit inside and outside for safety. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for resident use with plenty of shade. The facility has telephone and internet service for resident use. Activities: During the visit LPA observed residents actively involved in facility activities (singing, watching TV, exercising, art). A musician played a flute for the residents. An activity calendar is displayed in the great room. (Continued LIC809-C) Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binders for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. All trash cans and wastebaskets have tight fitting covers. Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 07/17/2025. The facility is approved for a capacity of 8. The fire clearance is granted for 8 Non-Ambulatory of which 4 may be bedridden. Hospice is approved for 4. Staffing: Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening, and fingerprint clearance/Associations/exemptions. Administrator Certificate expires 09/30/2026. Personnel Records & Training: Facility keeps records confidentially. Fire and Disaster drills are conducted quarterly. Facility staff have current First Aid and CPR training with valid certificates. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. LPAs reviewed resident file for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Emergency and ID forms, all forms were legible, and records are kept confidential. Food Service: LPA observed 2-days perishables and 7-days non-perishables to meet the food service requirement. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies. (Continued LIC809-C) Incidental Medical Services: Facility provides transportation or assist in providing transportation to medical and dental appointments when needed. LPA reviewed centrally stored medication records. Medications were kept in the original containers. While visiting LPAs observed Home Health personnel and the visiting physician reviewing resident care. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were last inspected on 09/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not currently have residents with oxygen. The facility has 3 resident currently on hospice. The facility has 2 residents receiving Home Health services. Hospice and Home Health plans are kept up to date and on file. Hospice and Home Health train staff on residents care. The facility does not have delayed egress or locked doors. The facility has exiting door alarms. LPA interviewed 2 staff working at the facility and 2 residents. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.