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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a pre-licensing inspection for a change in ownership. LPA met with Elena Docmanov, Lead Caregiver (Admin Designee) and explained purpose of inspection. Also present were caregivers, Ethel Haughten and Winnifred Morris Graham. Administrator, Anamaria Docmanov, virtually attended the Comp III portion of the inspection. LPA observed (6) residents present and was advised (2) residents are currently under hospice care. There is currently an approved hospice waiver for (2) residents.
LPA and Administrator Designee toured the interior and exterior of the facility including the common areas, (6) private resident bedrooms, (3) resident bathrooms with showers, kitchen, office, locked laundry and medication area and garage. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting and the bathrooms to have the necessary grab bars, non-skid flooring, and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and sharps, toxins and medications to be locked in the kitchen using magnetic locks. LPA observed additional locked toxins in the laundry area. LPA observed a covered patio table and chairs and (1) unlocked exit gate in the backyard. (LPA observed maintenance staff to begin to change the handle lock to one that only locks from the outside). The inside temperature measured 78*F. Fire extinguisher was last serviced on 8/23/2022 and all doors have alarms. LPA observed a complete First Aid kit except for tweezers and sufficient PPE and paper supplies. All smoke/monoxide alarms were recently tested by the fire department and were functioning. Water temperature measured 108*F in a bathroom. LPA observed sufficient linens/towels/blankets. LPA observed various required postings posted- Administrator to post Theft & Loss Policy. All staff are fingerprint cleared and associated. LPA observed all staff files to be complete and contain current training documentation, including First Aid/CPR certifications. Resident files were reviewed and observed to contain all required documentation- Administrator to ensure care plans and physician reports are updated at least every 12 months, when required, and all paperwork is updated once new license is issued. Administrator to ensure tweezers are added to the First Aid kit and a small tear in a bathroom window screen tear is repaired. Component III was reviewed during today’s inspection. Pre-Licensing is complete and this facility has no deficiencies.
Exit interview. Copy of report left at facility. LPA to notify to the Centralized Applications Bureau. |