Routine inspection·November 6, 2025

Licensing Program Analyst (LPA) De Leon arrived at 11:50am to conducted a 1 year annual visit to the facility above. LPA met with Staff Paraluman Tatsuo, whom called Administrator. Administrator Abiy Tesfazgy arrived shortly and LPA 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: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder 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. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE) initially and annually thereafter. Operational Requirements: The facility has a current plan of operation and infection control plan 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 12/01/2025. The facility is approved for a capacity of 6 with 6 Non-Ambulatory. Hospice approved for 2. Physical Plant & Environmental Safety: The facility is a 4 bedroom and 2 bathrooms currently occupying 3 residents and employs 3 full time staff and 1 Administrator. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has an fenced backyard for client use with plenty of shade. The gate on the sides of house are self closing and self latching. The facility has telephone and internet service for resident use. Continued 809-C Staffing: The facility employes 3 full time staff and 1 Administrator. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator Certificate expires 09/2027. Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have training with 20 plus hours meeting topics to cover for 2024-2025. Required forms are present. Residents Rights and Information: All required personal rights are posted. CCL and LTCO Complaint posters are posted. Emergency Plan, Licnese, Non-Discrimmination is posted in the common area of the facility. The facility offers telephone and internet service to residents in care. Planned Activities: The facility has an acitvity calendar, puzzles, games, books and TV. There is enough space inside and outside for activities. Residents do the activities they like and want to do. 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. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. 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. Kitchen staff are observed for personal hygiene and food sanitation practices. Incidental Medical and Dental Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA checked medications for all 3 residents, medication labels were not altered, medications were stored in original containers and no expired medication was found. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 3 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible and completed in separate confidential binder for each resident in care. Continued 809-C Disaster Preparedness: The old emergency disaster form was posted. Administrator updated the current version and posted. The facility conducts quarterly disaster drills. The fire extinguishers was charged and last inspected on 11/20/2024. 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. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care in laundry room. The facility has 1 resident currently on oxygen and a sign is posted. The facility does not currently have any hospice residents in care. Hospice care plans are kept on file and up to date when needed. The facility currently has 2 residents receiving Home Health services. Home Health services records are kept on file. The facility does not have delayed egress. Exit doors have alarms. LPA interviewed 2 staff and 2 residents. Administrator had to leave the annual early and authorized staff to sign report. Exit interview conducted, copy of report printed for facility.