Routine inspection·March 22, 2023

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 03/22/2023 at 01:32pm. LPA met with facility staff member Abijaun Burchell (S1). S1 contacted the facility administrator Sylvester Okoro (Admin). Admin stated that he would not be able to attend the inspection in person and gave S1 permission to conduct the inspection/sign reports in his stead. LPA toured the facility, including kitchen, living room, staff room, 2 bathrooms, 4 resident rooms, garage, and back yard. S1 confirmed that all staff and residents have been vaccinated. All residents and staff have received their booster shots as well. Facility infectious control plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility water temperature measured at 110*F. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in October 2022. Smoke/carbon monoxide detectors tested and observed to be operational. All staff members present at the facility were observed to be fingerprint cleared on Guardian. LPA reviewed 4 out of 4 resident files, all resident files were observed to be incomplete and and out of date. 0 out of 4 files contained a physician's report less than a year old. 0 out of 4 files contained a completed needs and services assessment. 4 out of 4 files contained completed admissions agreements. S1 called Admin to inquire about up to date documents. Admin stated that he has up to date digital copies, but that he was not at his computer and needed about an hour to send the documents. LPA did not receive the documents. LPA attempted to contact the administrator two hours later, at 03:42pm and 04:04pm, but was unable to reach him. At the time of this writing, LPA has still not received up to date documentation from the Admin. Deficiencies cited during today's visit. This report was reviewed with facility staff member Abijaun Burchell, who signed on behalf of Administrator Sylvester Okoro and a copy of the signed report was provided digitally due to printer error.