Facility Evaluation Report

Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection and met with Administrator Dumitela Dimapilis. LPA explained to the Administrator the purpose of the visit.

During the visit, LPA inspected the facility inside and out including but not limited to resident rooms, bathrooms, kitchen, dining, garage and backyard. Hot water measured at 115.8 Fahrenheit. There was sufficient supply of perishable and non perishable foods. LPA observed sufficient supply of warm blankets, sheets and towels available for use of the residents. Administrator states two of six residents are in the hospital. Smoke detectors and carbon monoxide were tested and observed functional. First aid kit was observed to be complete.

At around 11:43 am, LPA reviewed 5 resident and 3 staff files. At around 4:00pm, LPA interviewed staff and residents.

The following deficiencies were observed:

1. Physical Plant/Environmental Safety - - Unused bed, recliner, mattress, hoyer lift, cart, ripped screen door in the backyard and refrigerator light out were observed during the inspection.

2. Physical Plant/Environmental Safety - - Bathroom disorganized and smelled urine.

3. Physical Plant/Environmental Safety - Comet unlocked under the sink. Lysol unlocked in the unlocked drawer inside the resident's room.

4. Residents with Special Health Needs - R1 developed stage 3 pressure injury in July 2023 but no reappraisal was conducted.