Routine inspection·August 14, 2023

Licensing Program Analysts (LPAs) Victoria Bertozzi and Helena Rummonds arrived unannounced to conduct an Annual Required inspection and met with Licensee, Sophie Fletcher. LPAs initiated a tour of the facility around 11:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 113 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the garage along with Personal Protective Equipment. Fire extinguishers were last serviced July 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 7/2023. Four staff files and four resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Sophie Fletcher has expired but is on the Department's Pending List. Medications and medication records were reviewed. Continued on LIC809C Continued from LIC809 Licensee/Administrator to submit updates of the following documents by 9/14/2023: LIC 500 Personnel Summary Copy of Liability Insurance LIC 610 Emergency Disaster Plan (If changes) Infection Control Plan (If changes) No deficiencies cited during this inspection