Facility Evaluation Report

At approximately 09:45AM, Licensing Program Analyst (LPA) Ali Deniz made an unannounced annual inspection of this licensed senior care facility. LPA met with facility Licensee/Administrator, Ermelinda Mahlman. There is a total of six residents at facility, two with dementia, and 1 resident on hospice.

Facility is a 1 story building with 9 Resident bedrooms, 1 staff bedroom, 4 bathrooms, and common spaces.

At approximately 10:00AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted except the Complaint Poster PUB 475 was not posted in the facility (Technical Advice given). LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of cleaning up after breakfast at the time of this inspection.

During walk-though LPA/Administrator observed knifes were unlocked and administrator stated that they only clock the knife drawer and cleaning supply cabinets during the nighttime. Toxins are stored in a secure room of the kitchen. Although sharps and toxins in kitchen cabinets were unlocked (See LIC809-D page). Water temperature measured within regulation between 105- and 120- degrees F at faucets accessible to residents. Fire extinguishers inspected were charged and last inspection on 06/14/2024. Smoke detectors are hardwired into the fire system. Facility has fire sprinklers throughout. Fire suppression system was last inspected January 2024. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

At approximately 12:10PM, LPA reviewed 5 of 6 resident records and found 1 out of 5 resident R1 did not have current physician's reports or care plans. R1’s last medical assessment has done in Feb 2024 (Technical Advice given).