Facility Evaluation Report

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Irina Maroussenko and explained the reason for the visit. The facility is a 6 bedroom house (1 bedroom is for staff) with 2 bathrooms, kitchen, dining room, living room and an attached 3 car garage. The facility is licensed for 6 non-ambulatory residents with a hospice waiver for 4. Irina Maroussenko Administrator's Certificate expires on June 14, 2028. LPA and Administrator toured the facility. LPA observed the PUB 475 poster posted in the entry way of the facility. The garage is kept locked and used for storage. Smoke detectors and the carbon dioxide detector tested operational. The fire extinguisher mounted in the dining room is fully charged. The last emergency drill was conducted on June 10, 2025. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed a 3 day supply of emergency food and water stored in the kitchen. LPA observed knives are kept locked in a box on the kitchen counter. The 5 burner gas stove lights unassisted. LPA observed the fireplace in the living room is screened. LPA and the Administrator toured the resident bedrooms. All resident bedrooms were clean and organized. All the resident bedrooms had the required furniture and bed linens. LPA observed all residents had half or quarter bed rails. All 5 residents had the proper doctor's order for bed rails. LPA observed both bathrooms are clean and operational. Hot water measured 116.2 degrees Fahrenheit in both bathrooms. LPA observed medication is kept locked in a medication cart kept in the staff bedroom. LPA and the Administrator toured the backyard. No bodies of water observed. There is a covered patio with chairs for residents to sit outside. The exit gate is operational. No obstacles or hazards observed in the backyard. LPA reviewed 5 resident files and medications. No discrepancies observed.