Routine inspection·March 27, 2025

Licensing Program Analyst (LPAs) Christi Coppo and Ethel Contreras arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Julius Vegvary and Mercedes Vegvary. At approximately 9:30am LPAs and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. Laundry room located off kitchen was locked and all cleaning supplies were locked in cabinets. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean. Room #3 has flooring that is worn and lifting up such that it could present as a tripping hazard. Admin agrees to immediately replace and send pictures of replacement to CCL no later than April 17, 2025. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sinks accessible to residents in care did not measure within regulation upon first measurements. Admin immediately adjusted water heater temperature and LPAs tested the water again after a period of time. Water then measured at 112.2 degrees F in the cottage, which is within the allowable range of 105 to 120 degrees F. Admin and licensee agree to keep an eye on the water temperature. Fire extinguishers were last inspected 2/27/25. Smoke/Carbon Monoxide detectors located throughout the facility and cottage are hardwired, along with sprinklers, and are serviced by a vendor. Detectors are serviced annually and were last serviced March 2025. Facility’s last quarterly disaster drills were conducted 12/31/24. LPA reminded Admin to conduct drills quarterly. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809... At approximately 11:00am LPA conducted review of five [5] staff records. CPR card present for S1 but not First Aid, card stated AED/CPR for Infant and Child but no First Aid completed. Admin was unaware that training did not include First Aid. All other staff have First Aid completed. Admin will have S1 complete First Aid by no later than 4/2/25. LPA reviewed staff training documentation and materials. Admin is using CCL PINs and printed handouts from Advanced Healthcare Studies, no publication date present, but appears to be outdated. LPA reviewed documentation of training which appeared to be fabricated: all training dates for staff conducted on the same day for all 5 staff members, some hours listed showed as many as 8 hours of training conducted on the same day. LPA asked Admin if all five staff are receiving training and she is the one conducting the training. who is attending to the residents. LPA also observed training documentation to be photocopied, no variation in dates or duration of time. Admin confirmed that training documentation was photocopied, but stated that it was not fabricated. LPA discussed with Admin the option of using an approved vendor to conduct training and print out the certificates issued as documentation, this could potentially mitigate the appearance of any fabrication. LPA also discussed with Admin the other option of purchasing training materials that are current, Admin will then submit the current training materials to CCL for approval. At the time of submission, Admin agrees to also present to LPA an example of how they will document the training. LPA and Admin will discuss together if the process by which the training will be documented is within regulation. Admin will submit training materials for approval no later than April 25, 2025. At approximately 1:00pm LPA conducted a review of six [6] resident records. All required documentation present. 1/2 rails present and on file for all residents for which they are required. At approximately 2:30pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet. No deficiencies Julius Vegvary Administrator Certificate 7007660740 expired 11/14/2024. Continued on 809C(2)... Continued from 809C... Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Exit interview conducted with Administrator and a copy of this report was given . No deficiencies cited