Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne conducted unannounced case management deficiencies visit at the facility today. LPA arrived to the facility at 10:15 AM. LPA met with the facility staff, staff #1 (S1) who contacted the facility Administrator Emma Avetisyan via telephone call. The Administrator arrived to the facility at approximately 12:30 PM. Entrance interview conducted and the reason for the visit was explained.

During today’s visit, the LPA conducted a physical plant tour to ensure there are no health and safety hazards, collected copies of pertinent documents, conducted a medication audit for one (1) resident, and conducted interviews with the Administrator, one (1) staff member, one (1)resident, and one (1) witness between 10:20 AM and 02:00 PM

During the physical plant tour LPA observed the flooring near the exit located in the kitchen to be bubbling up, held together with tape, and in disrepair. Additionally, LPA observed the closet door located in bedroom # 2 to be detached from the railing and in disrepair. LPA observed a light switch cover in the shared resident bathroom to be broken and had sharp exposed plastic. LPA informed the Administrator of the items that were in disrepair and the Administrator agreed to perform the needed repairs to the identified items.

During an interview with S1 and the Administrator LPA was informed that resident #1 (R1) was recently hospitalized after a medical incident. LPA reviewed the facility file and their inbox and did not observe an incident report submitted for the hospitalization of R1. LPA informed the Administrator that incidents must be reported to Community Care Licensing Division no later than seven days following the occurrence of the incident. The Administrator expressed understanding and submitted a report for the incident at the time of the inspection.