Routine inspection·May 22, 2025

On 05/22/2025 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Staff, Joy Awa and Julietta De Jesus. Licensee, Rose Marie Devera arrived during visit at approximately 10:00AM. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. The facility currently approved for capacity of 6 residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 4 residents in care and 2 staff members on-site. Facility is a 1 story building with 4 Resident bedrooms, 1 staff bedroom, 2 bathrooms, and common spaces. At approximately 9:50 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:35AM, LPA and Licensee toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. During the tour LPA observed two gardening beds in the backyard needs repair on the sidewalk. Licensee agrees to repair them as soon as possible in a week. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of cleaning up kitchen at the time of this inspection. Toxins are stored in a locked housekeeping closet in the hallway. Water temperature measured 110.6 degrees F and 113.4 degree F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers inspected and charged on 06/07/2024. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet in the dining room. Continued on LIC809-C… Continued from LIC809… At approximately 11:45AM, LPA reviewed 4 resident records and found 4 of 4 residents have current care plans, signed admission agreements, and physician's orders on file. However 1 out of 4 residents did not have current physician's report on file. Last physician's report for R1 dated to 05/01/2024 which is over a year since last medical assessment have done. Licensee stated that they have done medical assessment for R1 previously however the licensee wasn’t able to find in file (Technical Violation given). Licensee agrees to submit updated medical assessment to the CCL before 06/02/2025. Medication records are thorough and contained physician's orders for each resident. At approximately 12:25PM, LPA reviewed 3 staff records. 3 of 3 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were present. LPA was presented with proof of current CPR & 1 st Aid certification for staff. Administrator Certificate is for Rose Marie Devera #7033992740 expires 11/01/2026. LPA reviewed the facility emergency disaster plan. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 04/04/2025. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 06/05/2025: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Licensee. Signature on form confirms receipt of documents .