Routine inspection (multi-day)·November 28, 2023

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to continue the required Annual inspection and was greeted by Kennedy Wainaina, Administrator. Facility currently has five (5) residents in care none of which are currently on hospice. At approximately 12:50pm LPA and Administrator spoke about annual fee being past due. LPA gave Administrator copy of LIS pin # and print out of fee chart with late fee assessed as of 11/23/2023. LPA advised Administrator non-payment could result in a citation. Administrator immediately paid online and LPA observed payment confirmation. LPA reviewed Guardian employee roster with Administrator and verified all current employees are associated and have fingerprint clearance. At approximately 1:00pm LPA reviewed 5 of 5 resident files. At approximately 2:00pm LPA reviewed 5 of 5 staff files, excluding Administrator files. At approximately 3:00pm LPA and Administrator did a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in the kitchen. 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 Exit interview conducted with Administrator and a copy of this report was given. No deficiencies cited during this inspection.