Facility Evaluation Report

On December 20, 2024, at 8:40 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the LVN, Mengist Redie and disclosed the purpose of the inspection. “No Smoking - Oxygen in Use” sign was posted at the front entrance door. Manager, Africa Garlejo arrived shortly after. The Manager informed the LPA that the facility currently has 4 staff on duty and 4 residents in care, all (4) residents are non-ambulatory and are on ventilators.

At 8:55 AM, the LPA initiated a walk-through of the facility, accompanied by the Manager.

LPA inspected the kitchen and found it clean, with no food preparation or cooking in progress at the time. Manager stated that appliances in the kitchen are for staff use only. No meals are prepared for the residents in care. All residents eat though tubes. The locked cabinet containing knives and the locked cabinet under the sink with soap and cleaning supplies were also inspected. LPA inspected the refrigerator and observed a locked box for storing rectal suppositories.

LPA inspected the dining area and observed it clean, with all the furniture in good repair. LPA inspected the fire extinguisher mounted on the wall in the kitchen and found it was fully charged with a last service tag of 06/26/2024. The manager tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. LPA inspected the living room and observed activities calendar posted with list of activities for each day.

There are (5) bedrooms and (1) bathroom designated for residents' use, and (1) bathroom designated for staff, and (1) office room. All resident rooms are private occupancy. LPA inspected all (5) resident rooms and found them clean, well-lit, and equipped with the required furniture. Each resident room contained resident’s incontinence, respiratory, and linen supplies.

LPA inspected the common resident bathroom and found it clean, sanitary, and in operating condition. It contained shower gurney, shower curtain, soap, grab bars, a trash can, and non-slip flooring. The hot water temperature at the sink faucet was measured at 109.2°F.