The facility has a fire clearance for 6 non-ambulatory residents only. At this time, the facility is not approved to accept or retain any residents who are bedridden, nor does it have an approved hospice waiver. LPA conducted a tour of the facility, inspecting both the interior and exterior. Common living spaces, resident bedrooms, bathrooms, the kitchen, and other areas intended for resident use were all toured. It was noted that the furniture and furnishings were adequate and in good condition to meet the needs of the residents at this time. The laundry room was also inspected, and LPA observed that laundry detergent, bleach, and other cleaning supplies were safely stored and inaccessible to residents. All required postings were visible throughout the facility. Smoke and carbon monoxide detectors were tested and found to be in good working condition. A fire extinguisher, located in the family room, was observed to be serviced and valid until 11/27/2025. LPA toured all five resident bedrooms, as well as one caregiver room. All furniture and furnishings appeared to be in good repair; however, LPA Lee observed that the bi-fold closet doors in Bedrooms #1 and #3 require knobs to allow residents to open them properly. Additionally, the closet doors in Bedrooms #4, #5, and #7 were found to be in despair and difficult to open.

Continued LIC 809-C

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

In the kitchen, LPA observed an adequate supply of food at least two days’ worth of perishable and seven days’ worth of non-perishable items sufficient to meet the residents’ needs. Kitchen knives were securely locked and inaccessible to residents. The facility’s internal temperature was observed to be 71 degrees, and a public telephone was available in the kitchen for residents’ use. The linen closet, located in the hallway, contained sufficient supplies of clean towels, blankets, and bed linens. Medications were stored in a locked centralized cabinet located in the laundry. Together with the applicant, the resident’s medications with the medication logs were reviewed, which were found to be complete and accurate. File reviews were conducted for five residents and two staff members. 1 out of 5 resident files were incomplete. Resident 1 (R#1)’s LIC 601 Identification and Emergency Information was incomplete and signed. R1’s LIC 603A Resident Appraisal is also incomplete but signed by the administrator Julie Nonu and has no resident signature. LPA reviewed two staff files, and they were incomplete. Staff #1 (S1) LIC 501 is incomplete. S2’s LIC 501 Personnel Record is also incomplete. S2 is also missing LIC 503 Health Screen and TB. The First Aid Kit was present and contained the required items. Outside the facility, the physical plant was in good repair, free from hazards. The perimeter fencing was secure, and all gates were in working condition.

During today’s visit, LPA Lee observed that the interior layout of the facility does not align with the submitted and approved facility sketch. According to the approved sketch, bedroom #7 is designated for one non-ambulatory resident, and bedroom #5 is designated as a staff room. However, during the inspection, it was observed that:

· Bedroom #7 is currently being used as a staff room

· Bedroom #5 is also being used for residents

Continued LIC 809-C

The following corrections must be made prior to licensure:

· Submit an updated facility sketch that accurately reflects staff and resident room per the approved fire clearance

· Repair the closet door in Bedroom #7 to ensure it is in good condition

· Install knobs on the closet doors in Bedrooms #1 and #3 to allow residents to open them easily

· S1 LIC 501 Personnel Record needs to be completed.

· S2 LIC 501 Personnel Record needs to be completed and needs LIC 503 Health Screen and TB prior to working at the facility.

Based on the observations made during the visit, the applicant has not passed the Pre-Licensing component. LPA will notify CAB that the Pre-Licensing visit was not approved. An exit interview was conducted, and a copy of the report was provided to the applicant Tevi.