Facility Evaluation Report

On 3/15/2023 at 9:30 AM, Licensing Program Analysts (LPAs) L. Francisco and C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Meeran Saxena and explained the purpose of the visit. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden residents. There are 6 residents and 4 staff present during inspection.

LPAs toured facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 6 bedrooms are occupied by the residents and 2 bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was serviced on 1/9/2022 Emergency Disaster Plan was last posted on 3/15/2023. First aid kit was observed to be complete.

At 11:15 AM, LPAs reviewed 3 staff records and 2 of 3 have current first aid training and at least 1 staff have CPR training per shift. At 1:40 PM, LPA reviewed a sample of resident's medications.