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32 | BATHROOMS: The facility has a total of three (3) bathrooms. Two (2) are resident bathrooms of which one (1) is a shared resident use, one (1) is a private resident use, and one (1) for staff use. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. Hot water was measured in resident bathrooms. The shared bathroom measured at 119.3 degree Fahrenheit and the private bathroom at 117.2 degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. OUTDOOR SPACE/ GARAGE: The LPA observed the back yard which had a shaded patio area with patio furniture including a table and chairs for resident use. The LPA observed one gate that self-latches with a clear passageway in case of an emergency. There were no bodies of water observed on the premises at the time of the visit. The garage is kept locked and inaccessible to residents. LPA observed an extra refrigerator with extra food that was checked for proper labels and expiration dates.
At approximately 11:15 a.m., all smoke detector(s) in the common areas and resident rooms was tested and functioned properly. Some of the smoke detectors were dual carbon monoxide detectors and operational at the time of testing during today's visit; a single carbon monoxide detector located near resident room was also tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 1/27/2026.
RECORDS: Records review began at approximately 12p.m.; six (6) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All resident records observed complete with all required documents. At 1p.m. five (5) Staff records including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the annual required training. All required staff records were in order including the required annual training. One (1) staff, three (3) resident and visiting family were interviewed during the inspection. Staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns noted or voiced at the time of the visit. Documents requested to be sent to the Department during the visit include: LIC 500 staff roster, and current Liability Insurance.
MEDICATIONS: Medications review began at approximately 2:15 p.m. Medications are centrally stored and locked in a kitchen cabinet; medications are labeled and are recorded and dispensed accordingly. First aid kit observed complete and included a manual.
No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
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