Facility Evaluation Report

On 03/26/2024 at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Ana Breen and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory.

LPA toured facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are available for residents and 2 bedrooms is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. The pool is locked and secured. A comfortable temperature is maintained at 78 degrees Fahrenheit. 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 111.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is not a minimum of one week supply of nonperishable and 2-day of perishable foods once expired and spoiled food was discarded. Centrally stored medication and sharps were not locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/29/2023. Emergency Disaster Plan was last reviewed on 10/05/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 02/16/2024.

At 11:00AM, LPA reviewed 1 of 1 residents records. At 11:30AM , LPA reviewed 3 of 3 staff records and 3 of 3 have current first aid training and arenassociated to the facility.