Facility Evaluation Report

On 2/17/2024 at 9:45AM, Licensing Program Analyst (LPA) C. Fowler conducted an unannounced 1-Year Required inspection. LPA met with Sarah Horny, Caregiver, and explained the purpose of the visit. LPA spoke to Administrator Shirley Marshall currently holds a certificate (#6005261740) that expired on 06/26/2023 Administrator. The facility’s fire clearance was approved for sixteen (16) non-ambulatory residents.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, and sideyard. The facility consists of five (5) total and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 135.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/4/2022. Emergency Disaster Plan was posted. First aid kit was observed to be complete.

Administrator file was incomplete and two (2) of the (3) staff files are missing CPR and education/training which is considered incomplete. Both resident files are complete.