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25 | On 6/15/21 Licensing Program Analyst (LPA)s Shaunte Henry and Anna Bueno arrived at the facility to conduct an announced pre-licensing inspection. LPA met with licensee/Administrator, Selina Abrudan explained the nature of the inspection and was granted entry to the facility. LPAs toured the facility inside and out with including, but not limited to the bathrooms, bedrooms, dining areas, kitchen, and laundry. The facility’s fire clearance was approved for non-ambulatory and X bedridden. There are 7 bedrooms total (4 are designated for residents). The facility has a total of 3 bathrooms and 2 are designated for residents. There is a dementia plan of operation on file.
The kitchen was free from hazardous items. Toxins and cleaning supplies were kept in a locked cabinet underneath the sink. LPAs observed canned foods. Emergency food was observed. Sharp objects were stored in a locked drawer in the kitchen. The laundry area was locked and inaccessible. The fire extinguisher was fully charged and last inspected.
The resident’s bedrooms were clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained in hallways and bathrooms. The bathrooms are clean and equipped with grab bars and non-skid surfaces and in the showers. LPA observed additional linens, towels, hygiene items. Medications will be kept in a locked cabinet in the kitchen. The first aid kit was complete. Carbon monoxide & smoke detector were tested and functioning properly. Auditory devices were operable on all exit doors. No firearms or ammunition were stored at the facility. The outside of the facility is free from obstruction and the side gates remain unlocked. No bodies of water were observed. Resident and staff files will be kept inaccessible. The licensee/administrator contained the required training for persons with dementia as well as current FirstAid/CPR certification. The administrator’s certificate expires on 11/30/21. The facility appears to be ready for licensure.
An exit interview was conducted where this report was discussed with and provided to Selina Abrudan. |