Inspection Report Summary
Most inspections found no deficiencies, with clean reports in early 2022 and the most recent visit on January 6, 2025, showing the facility was clean, safe, and in good repair without any deficiencies. The December 12, 2023 inspection cited deficiencies related mainly to staff training, including missing current CPR/First Aid certification and emergency disaster preparedness documentation, as well as incomplete medication contact records. A follow-up visit on February 28, 2024 confirmed these issues were corrected. There were no fines, enforcement actions, or severe findings noted in any report. Several complaint investigations were not present or unsubstantiated in the available records.
Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 4
Capacity: 11
Deficiencies: 0
Jan 6, 2025
Visit Reason
The visit was an unannounced required annual inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be operating within its approved capacity, clean, safe, and in good repair with no deficiencies cited. A technical assistance was provided regarding medication distribution organization.
Report Facts
Facility capacity: 11
Resident census: 4
Water temperature: 120
Inspection start time: 840
Inspection end time: 1235
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renese Howell-Small | Licensing Program Analyst | Conducted the inspection and provided technical assistance |
| Ruth Chinovsky | Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Follow-Up
Census: 6
Capacity: 11
Deficiencies: 1
Feb 28, 2024
Visit Reason
An unannounced Proof of Correction (POC) visit was conducted to verify correction of a deficiency cited during the facility's last annual inspection on 12/12/2023.
Findings
The deficiency 1569.618(c)(3) related to CPR/First Aid training was cleared as the licensee complied with the terms of the POC by completing the required training on or before 01/04/2024. A letter of cleared POC was issued during the visit.
Deficiencies (1)
| Description |
|---|
| Deficiency 1569.618(c)(3) related to CPR/First Aid training |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Bueno | Licensing Program Analyst | Conducted the unannounced Proof of Correction visit and reviewed findings. |
| Orfa Ruth Hernandez | Administrator | Facility administrator named in the report. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 11
Deficiencies: 4
Dec 12, 2023
Visit Reason
Licensing Program Analyst Anna Bueno conducted an unannounced required annual inspection to assess compliance with state regulations and facility operational requirements.
Findings
The facility was found to be clean, in good repair, and compliant with many operational and safety standards. However, deficiencies were cited related to lack of current CPR/First Aid certification for staff, missing PRN medication contact records, and absence of current emergency disaster training and drills for staff, posing potential health and safety risks.
Deficiencies (4)
| Description |
|---|
| Three staff files lacked current CPR certification, posing a potential health, safety or personal rights risk to persons in care. |
| Licensee could not provide contact records for resident physician for PRN/as needed medication administration, posing a potential health, safety or personal rights risk. |
| Licensee could not provide current emergency disaster training for all staff, posing a potential health, safety or personal rights risk. |
| Licensee could not provide documentation of quarterly emergency drills for all shifts, posing a potential health, safety or personal rights risk. |
Report Facts
Capacity: 11
Census: 6
Deficiencies cited: 4
Plan of Correction Due Date: Dec 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Orfa Ruth Hernandez Chernovsky | Licensee/Administrator | Interviewed and involved in findings related to staff certifications and medication records |
| Anna Bueno | Licensing Program Analyst | Conducted the inspection and documented findings |
| Nedra Brown | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 7
Capacity: 11
Deficiencies: 0
Feb 2, 2022
Visit Reason
The Licensing Program Analyst conducted an unannounced annual inspection with an emphasis on infection control as a continuation from a previous visit on 01/25/2022.
Findings
The facility was found to have proper infection control measures including adequate signage, hand hygiene supplies, cleaning provisions, and PPE use. No deficiencies were cited during this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Orfa Ruth Hernandez | Administrator | Met with Licensing Program Analyst during inspection and explained purpose of visit. |
| Javier Prieto | Licensing Program Analyst | Conducted the unannounced annual inspection. |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager. |
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