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25 | On 10/31/2024 at 08:12am, Licensing Program Analysts (LPAs) Zina Brown and Lizeth Villegas conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPAs met with Fabiola Marciano, Executive Director and the purpose of the visit was discussed. Facility is licensed to serve 91 non-ambulatory residents of which 10 may be bedridden, delay egress observed to be functional in memory care units which are floors, 2-4. There are 35 residents are diagnosed with dementia, 4 residents receiving home health, 10 residents receiving hospice care services. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facility does not handle any of the residents’ money. The liability insurance is current and expires 05/01/2025.
The facility is a 10 story building with eight (8) rooms on each floor, a basement, administrative offices on the first floor, rooftop patio. For the memory care, the facility is allowed to 13 beds and 13 residents. Also on the memory care floors #2 - #4 there are egress doors. LPA Villegas toured the resident bedrooms that had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between (118.0 F-120 F). Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.
Each floor has its own medication room.
LPA Brown & LPA Villegas conducted a records review of (10) client records, (9) staff records, (10) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records and did not observed any discrepancies at the time of visit.
Report continues on LIC-809
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