Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct a Plan of Correction visit and was greeted by Administrator, Victor Dada.

LPA is following up regarding deficiencies cited during the May 8, 2023 Annual Required inspection.

The following deficiencies have been corrected:

87202(a)(2) - Licensee submitted the LIC200 and Facility Sketch

1569.618(c)(3) - Licensee has submitted copies of staff's First Aid and CPR Certificates.

87506(b)(15) - Admission Agreements for noted residents have been completed

87458(b)(1) - R1 no longer resides in the facility

The following deficiency is not due until 5/31/2023:

1569.625(b)(2) - Annual Training for all caregivers

A fire clearance was requested and denied to retain a resident who is bedridden. During inspection, LPA learned that the resident has moved from the facility to a higher level of care. Licensee was provided instruction from the fire department indicating what would need to be changed in order to have an approved bedridden fire clearance. LPA explained that facility may not admit or retain a resident who is bedridden until the fire department approves a bedridden fire clearance.

No deficiencies cited during this inspection.