Facility Evaluation Report

Licensing Program Analyst (LPA) Natasha Persaud conducted an Plan of Correction visit. LPA was greeted and allowed entry into the facility and met with Staff, Norman Baloy.

On 10/25/23, an annual inspection was conducted and deficiencies were issued. The following deficiencies were issued: Maintenance and Operation - hot water measured at 150 degrees F.; Incidental Medical and Dental Care - medications stored in the fridge were not locked and the licensee was crushing and camouflaging resident's medications ; Reappraisals - current appraisals were not completed; and Liability insurance - Liability insurance was expired.

On 10/25/23, during the visit, the licensee posted warning signs over the sink indicating the water was too hot, which corrected the deficiency but the licensee was also supposed to ensure the temperature was in compliance. On 10/26/23, the licensee submitted proof of a lock box for medications, correcting the deficiency.

Today, LPA observed the hot water temperature measured at 141 degrees F., which is a repeat violation as the water is still not in compliance. Staff placed another warning sign over the sink. The medications were in a locked box located in the fridge. The licensee attended in-service medication training and provided proof of training. All residents now have current appraisals on file. The licensee obtained liability insurance and provided proof of insurance. All corrections have been made except for the hot water temperature.

Based on observations, a deficiency is being issued along with a civil penalty for a repeat violation within a 12 month period. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Staff, Norman Baloy whose signature below confirms receipt of these rights.