Facility Evaluation Report

On 4/2/2024, Licensing Program Analysts (LPA's) Tobola and Matialu arrived unannounced for the purpose of conducting a quarterly non-compliance visit and was greeted by Lead Caregiver staff, Charity Butler. Licensee, Mantu Sandhu arrived later in the visit. LPA's toured the facility with staff and observed the front door alarm and garage alarm in need of replacement. The Licensee was informed at a previous inspection but has not been addressed. Licensee, replaced the front door alarm unit at the time of visit.

The facility garage that holds chemicals, cleaning supplies and other items that could place residents at risk was found to be unsecured and accessible. Staff were not aware of where the lock for the facility garage was located, indicating a lack of safety measures implemented by the facility. The garage door frame is also in need of replacement. In addition, LPA's observed powdered bleach and a razor and located in communal restroom as well as a disinfectant solution in resident bedroom, all of which were unsecured. Licensee removed and stored items immediately.

During a tour of the facility, LPA's observed the facility in poor sanitary condition. Spiderwebs, spiders, ants and other insect remains were located in a majority of the rooms throughout the facility. Feces were found on the floor and open trash bin of resident's (R1) bedroom. Resident (R2's) bedrooms located near the front of the facility entrance were observed by LPA's to have a strong smell of urine that Licensee has been informed of in previous visits. Licensee has agreed to implement a documenting system for staff to sign off when conducting room cleaning and continence care for R2 and other residents that require the assistance. There is an overall need for general cleaning for the facility.

Multiple holes were found in several resident bedrooms walls in need of repair. In addition, window screens located in several resident bedroom and the kitchen area were found to be missing or in need of repair potentially causing insects to enter the facility.