Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Robertson Cirineo, Administrator; Josephine Credo, Licensee arrived later.

Once inside the facility, LPA/Administrator observed construction crew members present in the hallway near lateral exit making loud noise replacing the hallway flooring, while there were seven residents in the adjacent living room playing bingo, there were no posters alerting residents about construction zone, all materials and equipment were inside unlocked and accessible to residents in care. According to Administrator, construction crew members are only allowed in the construction area. Upon Licensee's arrival, LPA inquired about expectation of completion of the project and was told that expected time to be 4/3/26. However, Licensee did not report to the Department about the flooring replacement project and staff present were not observed reminding residents continuously to make sure that they are not going through the construction area. LPA requested written plan to be submitted to CCL and proof that resident's responsible parties were notified. The facility is not ensuring the health and safety of residents in care while the construction occurs. There are currently residents with a diagnosis of Dementia. Licensee instructed all staff present to frequently remind residents to be cautious when passing by flooring replacement area.

At approximately 1:00pm LPA/Licensee observed water temperature in resident's bathroom measured at 158.5, 158.5, 160.7 degrees F in the main building and 108.1 degrees F in the back building which are not within allowable range of 105 to 120 degrees F. Licensee printed signs to post in faucets used by residents and adjusted water heater. Continue on LIC809C...