Facility Evaluation Report

On 9-17-21 Licensing Program Analyst (LPA) Tirzah Hubbard and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced to conduct a Required – 1 Year inspection. LPA contacted the facility to ask follow up questions in regard to Covid-19. LPA spoke with the Administrator Karen Bhade to ask follow up questions for Covid-19 symptoms. Karen stated, " The facility has not tested positive for Covid-19 in the last 14 days. All residents are vaccinated and all staff are vaccinated at this time". LPA and LPM proceeded to approach the facility to conduct the Annual after the facility was cleared. All required COVID measures were not observed. LPA observed S1 and Administrator not wearing mask upon entry. LPA and LPM asked Administrator and Licensee to put their mask on for the duration of the Annual visit. The Administrator took the temperature of LPA and LPM but did not screen for symptoms. Administrator stated, the facility verbally ask the Covid-19 questions to ensure visitors are negative upon entry after they take temperature. The Administrator and Licensee agreed to create a document that provides the Covid-19 questionnaire to provide proof of each visitors symptoms.

LPA met with Administrator Karen Bhade and Licensee Narinderpal Bhade, and stated the purpose of today’s visit. LPA and LPM were allowed entry into the facility that is licensed to serve a total capacity of 6 clients. LPA interacted with a random number of residents during this visit. The physical plant was tour inside and outside to ensure the safety of the residents. All required furniture were observed. LPA observed residents engaging in activity, wearing a mask and practicing social distancing. LPA observed the facility conducts fire drills monthly. All bedrooms contained a dresser, bed, and night stand. The flooring of the facility has been replaced. LPA observed the thermostat 73*F temperature inside the facility hallway was measured at 74 *F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 106 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed 3 of 3 medications counted properly labeled and stored, matching medication administration records (MAR).