Routine inspection·May 21, 2025

Licensing Program Analyst (LPA) Rankin arrived at 9:10 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 Infection Control Plan. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. The facility is provided annual training for infection control with all staff. Physical Plant & Environment Safety: The facility is a 5 bedroom and 3 bathroom home currently occupying 6 residents and 3 staff and 2 administrators. 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 gates are self-latching and self-closing. 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. The facility is granted for 6 non-ambulatory with 1 can be bedridden and Hospice wavier granted for 4. Continued 809-C Staffing: The facility employes 4 staff and 2 Administrators. Staff records are kept confidential. Staff records were reviewed for 5 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. Administrator file was reviewed for continuing education and Administrator Certificate is valid till 04/18/2026. Personnel Records & Training: The facility keeps confidential binder with taps for each staff member. Training records were present for 2024-2025 for 20 plus hours of annual training. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five Files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Files are current meeting all required forms on file. 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 or assist in providing transportation to medical and dental appointments when needed. The medications records were reviewed for all 5 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 of residents medication, all medications were in original containers, prescription labels were not altered, No medications were expired, doctors orders were present and dispensing instructions were followed. Continued 809-C Disaster Preparedness: The current emergency disaster forms were posted. The facility provide disaster drills for 2025. 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. the facility had emergency food and water present. 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 does have 1 hospice residents in care, care plan is up to date and present. The facility does have one Home Health resident in care, home health plan is present and kept up to date. The facility does not have delayed egress. The facility does not have any current residents on oxygen. The facility has exiting door alarms, tested and working properly. Exit interview conducted, copy of report printed for Administrator.