LPA toured the physical plant in the presence of the staff member Henry Akapo. The facility was observed to be clean, in good repair, and maintained at a comfortable temperature with adequate lighting. During the tour, two staff members were seen present in the facility. Two residents were away at the day programs and two at their doctors appointment. The facility sketch includes 4 bedrooms, 2½ bathrooms, a living and family room, a kitchen with dining, a garage, and 4 exit doors for access to the exterior area of the facility. No accessible bodies of water or fire safety hazards were observed.

At 9:14 AM, LPA inspected all three residents’ rooms and observed them to be clean with sufficient furniture and operational light fixtures. All rooms are shared. The two full bathrooms were observed to be clean and contained non-skid mats, grab bars, trash cans, liquid soap, and paper towels. The bathroom #1 faucet hot water temperature was measured at 108.1°F.

At 9:26 AM, LPA observed an office room which is not included in the facility sketch. According to the Administrator, one of the bedrooms has been converted into an office room for a long time.

At 9:32 AM, LPA inspected the half bathroom and observed disinfectant, bleach, and other cleaning solutions were not stored/locked properly and accessible to the residents, which poses immediate health risk to the person in care.

At 9:42 AM, LPA inspected the kitchen and observed it to be clean. Toxins, cleaning supplies, and sharp objects were stored/locked properly and inaccessible to the residents. The facility had an adequate stock of food items, including 7 days of non-perishables and 2 days of perishables, with no expired items observed.

At 9:51 AM, LPA inspected the laundry area and observed it to be clean and equipped with a washer and dryer. The hallway closet was observed to contain an additional linen supply.

At 10:18 AM, LPA inspected the exterior grounds of the facility. The side yard passageway was observed uneven to walk on and an above the ground exposed tree trunk from a removed tree was observed in the backyard, which is a potential tripping hazard for the persons in care. Auditory alarms were observed to be working and operational on all exterior exit doors.

At 10:26 AM, LPA inspected the fire extinguishers, which were observed to be fully charged and last serviced on 09/2024. The smoke and carbon monoxide detectors were tested and observed to be operational.

At 10:36 AM, LPA completed the review of 4 resident and 6 staff records. All were observed to be complete.

At 10:42 AM, LPA audited the Medication administration records and observed them to be accurate. Resident medications were securely stored in a locked cabinet in the dining room. No expired medications were observed.

At 10:46 AM, LPA inspected the First Aid kit and observed it to contain the required supplies. Emergency drills are conducted monthly with the last drill documented on September, 2024.

The following updated forms are requested to be submitted to CCLD by 10/10/2024:

An exit interview was conducted. This report was reviewed with Henry Akapo, DSP, and a copy of this report along with appeal rights was left at the facility.