Routine inspection·June 18, 2024

Licensing Program Analyst (LPA) Rankin arrived at 8:30 am to conducted a 1 year annual visit to the facility above. LPA met Licensee/Administrator Gabriella Soo and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan and Emergency Disaster Plan. The facility has EPA approved disinfectants spray and cleaners. The facility has trash bins with covers. The facility has a 30 day supply of PPE. Physical Plant & Environment Safety : The facility is a 5 bedroom and 3 bathroom home currently occupying 6 residents and 4 staff, including the administrator. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The gate (on the street view right side of the facility) is being updated for ease of latching and self-closure. The facility has table and chairs available outside with shaded area for resident use. Laundry room has working washer and dryer. Operational Requirements: The Facility is operating in compliance with fire clearance. The facility provided current up to date liability insurance. All Dementia requirements are being met. Hospice wavier granted for 2, a request to update hospice waiver to 4 is being submitted. Staffing: The facility employes 2 staff and 2 Administrators. Staff records are kept confidential. Staff records were reviewed for 2 staff. Staff records had fingerprint clearance and associations with criminal record statements, personnel record or application, First Aid and CPR certificates and Health screening with TB results. Personnel Records & Training: The facility keeps confidential files for each staff member. Training records were current for required 2024 annual training requirements and additional training is scheduled. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four Files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), Immunization records, TB results, Personal Rights, and Safeguard for personal property and valuables. Files are in compliance. Resident Rights Information: All require postings were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, Nondiscrimination notice in addition to a CCL Complaint poster, and LTCO poster. Planned Activities: The facility offers activities to all residents in care. Activities include books, magazines ,newspapers, TV watching, daily walks, group discussions and communications, and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available in the garage. Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 4 residents with the Centrally Stored Medication and Destruct Records (CSMDR) all were up to date, legible and written as prescribed. LPA completed a full audit on two residents medication, all medications were in original containers, prescription labels were not altered, doctors orders were present and dispensing instructions were followed. Three residents had hospice care plans. Disaster Preparedness: The current emergency disaster forms were posted. The facility provide disaster drills for 2024, and will add additional drills to their schedules. The fire extinguishers were charged and receipt was dated within 1 year. The dual smoke and carbon monoxide detectors are present and hard wired throughout the facility. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility has a license for 6 Non Ambulatory which 1 may be bedridden on room 1. The facility does not have delayed egress. The facility does have one current residents with oxygen. The facility does have hospice and home health visits to the facility for residents in care. Exit interview conducted, copy of report printed for Administrator.