Facility Evaluation Report

Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a required annual inspection. After discussing the purpose of the visit and verifying that all staff present had received criminal record clearance and were associated to the facility, LPA met and toured the facility inside and outside with lead staff Edith Nantumbwe, after which Director Caroline Navrro arrived at the facility.

The tour included, but was not limited to bedrooms, bathrooms, living room, kitchen, dining room, and outside area. During the tour, the LPA observed a sufficient supply of extra linen and bathrooms contained grab bars and slip-resistant tiles. In the kitchen and in the garage storage, LPA observed a sufficient two (2) day supply of perishable and seven (7) day supply of non-perishable foods. The hot water temperature was in the safe range between 105 and 120 degrees, and a comfortable temperature was maintained throughout the facility. LPA observed that the fire extinguisher had been serviced in June 2021. The LPA observed that medications were centrally stored and properly labeled.

During the LPA's file review, he observed that physician orders were properly maintained. LPA observed that an Emergency Disaster Plan binder is maintained at the facility and adequate emergency disaster supplies were on hand. The emergency drill log indicated that drills are conducted monthly, the most recent of which had been conducted on 10/21/21.

A Type A citation was issued based on LPA observation of cans of paint outside, which posed an immediate health, safety or personal rights risk to persons in care.

Exit interview was conducted and a copy of this report and the Appeal Rights were provided to the administrator.