Facility-requested visit·August 20, 2024

On August 20, 2024 at approximately 3:00 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of conducting a Case Management-Licensee Initiated Inspection. Upon arrival, LPA was greeted at the door by Stephen Lawson, and was granted access into the facility. During today's Case Management-Licensee Initiated Inspection, LPA received a new STD 850 Fire Safety Inspection Request Report to ensure that the staff room located behind the laundry room is not utilized for a staff bedroom. On July 16, 2024, at approximately 01:00 PM, LPA conducted a Case Management-Other inspection and conducted a tour of the room located behind the laundry room and observed a bed inside the room which was not observed on the original STD 850 Fire Safety Inspection Request Report dated for January 10, 2020. LPA advised the Licensee on said day that the room would need to be inspected by the Local Fire Jurisdiction to ensure that the bedroom can accommodate a staff member. On July 30, 2024, the Local Fire Jurisdiction inspected the bedroom and notated on the STD 850 Fire Safety Inspection Request Report that the room is not to be used for sleeping. Furthermore, the STD 850 Fire Safety Inspection Request Report summarized that the room does not meet requirements for a bedroom. LPA conducted a tour of the facility on today's date and found that the room is no longer being utilized as a bedroom for staff. The room was observed to be utilized for storage related purposes. In addition, the STD 850 Fire Safety Inspection Request Report also notated that the facility can only accommodate 3 bedridden residents. LPA explained to the Administrator that the bedridden capacity has gone down to three (3). Community Care Licensing will update the facility license and send a new license to reflect that the facility can accommodate a capacity of six (6) non-ambulatory residents which three residents (3) can be bedridden. LPA advised the Administrator the overall capacity of 6 residents residents did not change. No deficiencies were observed or cited during today's Case Management-Licensee Initiated Inspection. Exit interview was conducted and a copy of this signed report was provided to the Administrator.