Routine inspection·December 10, 2024

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Sophie Fletcher was contacted by phone and gave caregiver permission to sign. Facility contact information was reviewed. At approximately 1:30pm LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA 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 off of kitchen contains cleaning supplies in locked cabinet. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 108.1 and 109.3 degrees F which is within the allowable range of 105 to 120 degrees F. Facility has hardwood flooring in kitchen, some planks/tiles were loose and adhesive needs to be reapplied. Per LPA discussion with licensee, facility has contractor that will be fixing loose planks/tiles. Licensee advised LPA that repairs will be completed within two weeks. Fire extinguishers were last inspected 9/9/24. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted on 11/2024. At approximately 2:30pm LPA conducted a review of 6 resident records. All required documentation present. 1/2 rails or faxed request for half rails were on file for respective residents. Continued on 809C... Continued from 809... At approximately 3:45pm LPA conducted review of 5 staff records. All required documentation present. At approximately 4:30pm LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies. Sophie Fletcher Administrator Certificate 7019221740 expires 5/19/25. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Liability Insurance No deficiencies cited during this inspection.