Inspection Report Summary
Most inspections found no deficiencies, including the most recent report from November 19, 2024, which showed the facility was clean, well-maintained, and fully compliant. An earlier inspection on January 22, 2024, identified several minor issues such as unlocked insect spray accessible to residents, medication log errors, an outdated physician’s report, and safety concerns with a BBQ grill accessible to a resident with dementia. These issues were addressed with plans of correction submitted and some citations corrected during the inspection. Older reports from 2021 and 2023 showed no deficiencies and noted good infection control and safety practices. The overall trend suggests improvement, with the latest inspection confirming compliance after the earlier minor findings.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 0
Nov 19, 2024
Visit Reason
The inspection was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate compliance with regulatory requirements.
Findings
The facility was found to be clean, in good repair, and compliant with safety and operational standards. No deficiencies were issued during this inspection.
Report Facts
Fire extinguisher service date: Feb 17, 2024
Fire drill last completed: Oct 5, 2024
Freezer temperature: -3
Refrigerator temperature: 35
Hot water temperature: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gurmit K Aulakh | Administrator | Administrator present during inspection and involved in facility tour |
| Jacques Leffall | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 5
Jan 22, 2024
Visit Reason
The visit was an unannounced annual inspection conducted to evaluate compliance with licensing requirements and facility regulations.
Findings
The inspection found several deficiencies including unlocked insect killer spray accessible to residents, medication not logged in the centrally stored medication log, an outdated physician's report for one resident, a BBQ grill accessible to a resident with dementia, and missing property inventory lists for three residents. Plans of correction were submitted and some citations were corrected during the inspection.
Severity Breakdown
Type A: 4
Type B: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Insect Killer spray container unlocked and accessible to residents. | Type A |
| Medication not logged in the centrally stored medication log for 2 residents. | Type A |
| One resident's physician report was not current. | Type A |
| BBQ grill accessible to resident with dementia. | Type A |
| Three residents missing property inventory list. | Type B |
Report Facts
Residents present: 6
Facility capacity: 6
Deficiencies cited: 5
Plan of Correction Due Date: Jan 23, 2024
Plan of Correction Due Date: Jan 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gurmit K Aulakh | Administrator | Facility administrator present during inspection and involved in correction of deficiencies |
| Kamaldeep Kaur | Licensing Program Analyst | Conducted the inspection and authored the report |
| See Moua | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Jan 4, 2023
Visit Reason
The inspection was an unannounced annual inspection focused on infection control conducted by the Licensing Program Analyst.
Findings
The facility was found to be in compliance with no deficiencies issued. Observations included proper infection control measures, adequate food and cleaning supplies, secured medications, and safe environmental conditions.
Report Facts
Capacity: 6
Census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gurmit K Aulakh | Administrator | Met with Licensing Program Analyst during inspection |
| Mai Yang | Licensing Program Analyst | Conducted the annual inspection |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Dec 10, 2021
Visit Reason
The inspection was an unannounced annual inspection focused on infection control conducted by the Licensing Program Analyst.
Findings
The facility was found to be in compliance with no deficiencies issued. Infection control measures such as mask use, social distancing, hand sanitizer availability, and proper storage of cleaning supplies and medications were observed. The facility was clean, fire safety equipment was up to date, and resident rooms were adequately furnished and spaced.
Report Facts
Facility Capacity: 6
Resident Census: 6
Fire Extinguisher Service Date: Feb 9, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gurmit K Aulakh | Administrator | Facility administrator present during inspection |
| Mai Yang | Licensing Program Analyst | Conducted the inspection |
| Melinda Hoffmann | Licensing Program Manager | Named as Licensing Program Manager on report |
| Donnaly Tanaka | Caregiver | Met with Licensing Program Analyst during facility tour |
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