Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver (S1). Caregiver (S2) arrived later. Administrator Fikre Gurja was contacted by phone. Admin out of the country. Admin gave caregiver S2 permission to sign. Facility contact information was reviewed. Facility staff roster was reviewed. S1 not associated to the facility. S1 has been working at facility since October of 2023. In addition to not being associated to the facility, S1 also does not have fingerprint clearance. Per Guardian background check system, S1 has an incomplete application and was notified of such on 9/17/2023 ( deficiency cited, see 809D and *civil penalty assessed* in the amount of $500 ). LPA advised S2 and S1 that S1 must leave the facility and not return to work or provide any care to residents until fingerprint clearance is obtained and they are associated to the facility.

At approximately 9:30 am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. LPA and caregiver observed package of Keebler Club crackers opened but not covered or labeled with date opened. Canned goods found to be stamped with expired Best If Used By (BIUB) dates: one can of Bruce's Yam 12/22/2023, one bottle of Hidden Valley Ranch dressing 5/30/2024, two [2] cans of S&W garbanzo beans 11/18/2023, one can of Swanson's chicken broth 11/11/2023. Frozen beef steak dated 10/27/2023 ( deficiency cited, see 809D ). Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives was open but has locking function.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bars. However, mats in all 3 resident bathrooms were found to have black and brown substance on the underside of the mat, two of which had the substance almost covering the entire surface, one of which had varied spotting of the black substance ( deficiency cited, see 809D ).