Facility Evaluation Report

On 1/31/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced himself, stated the purpose of the visit, and was greet by Staff (S1) Yuliana Yap, LPA was granted entry. 4 residents were present during inspection. Licensee (A1) Shemeles Kabteneh arrived shortly after LPA’s arrival.

LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. A sample of resident’s medications were checked and observed kept locked in medication cabinet. Clients’ MARS was reviewed. Morphine Sulfate 20 MG/1ML SOL .25 ML (5MG) by mouth or under the tongue every 1 hour as needed for pain or shortness of breath was observed in the refrigerator unlocked and accessible. Fire extinguisher reviewed with a service date of: 3/1/24. Fire drill not completed and no record observed in facility. Cleaning chemicals was observed stored and locked in facility cabinet. Residents bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 113.9 to 116.7 degrees in 2 bathrooms.

Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. No thermometers observed in freezer or refrigerator, therefore no temperature was recorded during visit. Carbon monoxide were tested and observed to be operational. All clients’ files reviewed. 2 out of 4 residents is missing Consent for Medical treatment form. 3 out of 4 residents are missing the Appraisal Needs and Services form. 3 out of 4 residents are missing the Safeguard for Property Values form. All staff files were reviewed. Licensee is missing LIC-501 or Employee/License application, Medication Completion Certificate and a written copy of completed education.