Post-licensing visit·October 20, 2023

At approximately 9:00AM, Licensing Program Analysts (LPAs) Victoria Bertozzi and Christi Coppo made an unannounced Post Licensing inspection visit. LPAs met with Licensee Phoebe Mungai. At approximately 9:30AM, LPAs toured the building and grounds which was found to be clean and in good repair. LPAs 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. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator, and freezer were clean, and food was stored properly. Toxins are stored in locked laundry room and locked under kitchen sink. Water temperature at faucets accessible to residents measured at 117.3F and 104.7F, respectively, which is within regulation. Fire extinguishers inspected 11/08/2022 were charged. Smoke detectors/Carbon Monoxide detectors were tested and functional. There was enough lighting in all common areas, resident rooms, and hallways. NIghtlights present in hallways. Medication is centrally stored in the locked kitchen pantry. At approximately 9:30AM LPAs observed facility to have enough supplies to operate for more than 72 hours in an emergency. At approximately 10:45AM, LPAs reviewed 4 resident records and found residents to have physician's reports, signed admission agreements, care plans and physician's orders on file. LPAs reviewed 4 of 7 staff records. CPR and first aid certificates were current. 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 LIC610E- Disaster Plan (if any changes) No deficiencies were observed in the areas inspected, No citations were issued during today’s visit