Facility Evaluation Report

On 3/7/23, Licensing Program Analyst (LPA), Kevin Mknelly, conducted a case management health and safety visit. LPA met with caregiver and explained the reason for the visit. LPA followed the Department's current Covid-19 precautions and wore a surgical mask while present .

Staff were prompted by LPA to wearing masks.

LPA did a inspection of the interior of the home. The home is clean and in good repair.

Three staff are present and resident needs appear to be met.

LPA conducted a file review of 4 of 4 resident files and 3 staff files.

Facility Staff used a door stop to hold a fire door open to resident rooms hall.

Staff were told that S4 cannot currently be present in the facility.

Hospice care training for R3 and R4 is not on file at the facility.

R1 and R2, who both have dementia do not have LIC 602 (physician report) or Needs and Service Plans on file dated within the last 12 months.

Staff files found a lack of current training on file. Last training on file dated from 2016. All three 1st aid certificates on file are expired in 2020.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Nina Lemence. Copy and appeal rights provided.