Routine inspection (multi-day)·April 11, 2025

Licensing Program Analyst (LPA) De Leon conducted a continuation annual to the facility above to complete the 1 year annual visit. LPA met with Back up Administrator Jessica Bailey and explained the purpose of the visit. LPA toured the inside and outside of the facility and the following was noted. 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 are visible in the guest bathroom. 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). Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on 05/20/2024. the facility is a two-story home with an elevator and stairwell. The facility has 6 resident bedrooms with on suite bathrooms and 1 common area restroom. 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. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats or textured bottoms. 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 land are locked in the laundry room. The facility has sufficient space inside and outside for activities and visiting. The facility has a gated backyard for client use with plenty of shade. There is a pond, pool and spa that are secured with fencing, locked gates, secured perimeter and inaccessible to residents. The facility has telephone and internet service for resident use. The facility does have video surveillance in the inside and outside common areas of the facility. Continued 809-C 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 4/29/2026. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory, 2 of which may be bedridden. Hospice waiver is approved for 6. 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. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices. Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. Residents have on-call Doctor that visits facility. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. 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. The facility has an emergency evacuation chair for the stairwell. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does accept Hospice and Home Health Services. The facility does not currently have any residents on Hospice Services. The facility currently has 3 residents receiving Home Health services. The facility does not currently have any residents on oxygen. Hospice and Home Health plan are kept current and up to date on reisdnets receiving those services. The facility does have a secured perimeter. The facility does have exiting door alarms for the safety of residents in care. Exit interview conducted and copy of report printed for Administrator.