Facility Evaluation Report

On 05/06/25 around 01:15 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required Annual Inspection. LPA was greeted by Nalini Bhutani, Co-Administrator (ADM). The facility’s fire clearance was approved for six (6) non-ambulatory residents; hospice waivers for two (42).

LPA requested the resident roster, staff roster, three (3) staff files, three (3) resident files. LPA observed a visitor sign-in log at the entry. Emergency Disaster Plan is posted. LPA and ADM toured the facility, including but not limited to bedrooms, bathroom, kitchen, common area, front yard and backyard. All indoor passageways were free of obstruction. There were not any bodies of water present. Residents were dining for lunch, and watching television. A comfortable temperature for residents was maintained at 72 degrees Fahrenheit (F), and the water temperature measured at 117.8 F. LPA observed lighting in all rooms to be adequate for the comfort and safety of all the residents. The bathrooms were safe, sanitary and in operating condition. Hand washing posters, auto air dryer, and soap observed at hand washing stations. Linen and hygiene supplies were available for all residents. PPE and paper goods remain sufficient. There is a minimum supply of 2-day perishables and 7-days of non-perishable foods.