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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual, met with Oksana Doldier, Administrator, and explained the purpose of the inspection. Also present was Michael Doldier, staff. LPA observed (5) residents to be resting in their rooms during the inspection. The facility is licensed for (6) residents - all (6) residents may be non-ambulatory, and there is a hospice waiver approved for (4) residents. Currently there is (0) residents on hospice.
LPA and Administrator toured the interior/exterior of the facility including the common areas, resident bedrooms (6), (6) resident bathrooms, activity/movie room, kitchen, laundry area/garage. There are (2) resident rooms in the main house and (4) resident rooms in the recent addition to the main house. LPA observed the facility to be clean, in good repair and odor-free. The bathrooms have the necessary grab bars, non-skid flooring, paper towels and 20-second hand-washing posters. There is sufficient 2+day perishable and 7+day non-perishable supply of food, and sharps, medications and toxins are secured in the kitchen. There are also locked toxins in the laundry area. All exit doors have auditory alerts. The inside temperature measured 73*F, and the hot water measured 118*F in a bathroom. Fire extinguisher was last serviced 11/18/24 and a fire drill was last completed 1/25. Facility to ensure they complete a different type of disaster drill, on each shift, quarterly. There is adequate PPE, linens, blankets, incontinent supplies and an emergency disaster kit. There is a complete First Aid kit and night-lights in the common areas. There is a walking path outside with trees, decorative birds and seating. There is (1) unlocked gate from the inside back patio. Required postings are posted in the common area. PUB75 to be enlarged to 20 x 26 poster size. LPA reviewed (3) resident files and (2) staff files. Files were found to be organized and contained current documentation. LPA reviewed medications for (1) resident- orders matched medications being administered. LPA reviewed updated Plan of Operation to include recent changes to Dementia Care Regulation(s). Administrator and staff have completed current training. Administrator certification #7002171740- exp 12/12/25. LPA obtained an updated copy of the current liability insurance, LIC308 and LIC500.
There are no citations being issued. Exit interview. Copy of report provided. |