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25 | At 9:25am on 03/20/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. LPA met with Licensee, Ernesto Caliboso, announced who he is and the reason for the visit. Administrator Cherlyn Cradduck joined inspection during file, and document review.
At 9;40am Licensee and LPA conducted a physical tour of the facility. This facility has 3 resident bedrooms of double resident occupancy, and 2 bathrooms.. The facility had a smoke and carbon monoxide detector that was tested and working properly during visit. LAP noted that the facility has working fire extinguisher and it is primed in the green as good. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked in cabinets. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use and front patio has plenty of shade from umbrella. The facility has telephone and internet service for resident use. LPA noted that there are at least 2 days of perishable foods and at least 7 days of non perishable foods on hand for all residents and staff. LPA noted that the medications are stored and locked the hallway closet. LPA conducted a sample medication audit and did not discover any deviancies. LPA also conducted a staff and resident file review. LPA reviewed facilities plan of operation that addressed dementia training and bedridden residents. LPA reviewed both emergency disaster plan and infection control plan to be updated.
Licensee, Administrator and LPA conducted a full review of the annual care tool modules. LPA noted that there were not citations issued as a result of the care tool modules review. LPA noted that there were no citations issued during this annual facility inspection.
Exit interview, report read, and report provided.
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