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25 | Licensing Program Analyst (LPA) David Roman conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator, Sherwin Marcos. According to the facility’s license, the facility has a maximum capacity of six clients, of whom all may be non-ambulatory and one of which may be bedridden.
LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order, water temperature was measured at 105 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.
Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to client. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water on the premises. Per Sherwin Marcos, no firearms or ammunition are kept at the facility. Carbon monoxide detectors and smoke alarms were tested at 1:15PM, emergency lighting, and facility telephone were all working. Fire extinguishers were present and serviced on 02/06/2025. First aid kit was complete and readily accessible.
Resident records reviewed had required documentation. Staff records reviewed contained required documentation. However, the facility is missing the Plan of Operations manual. Licensee, Michelle Retzer reported to email the documents to LPA within the next two weeks.
An exit interview was conducted with Administrator, Sherwin Marcos and Licensee, Michelle Retzer, to whom a copy of this report and the Licensee/Appeal Rights were provided during the visit. Their signature acknowledges the receipt of their rights.
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