Facility Evaluation Report

On 10/4/2023 at 10:15am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Mary Burgess-Shaw, Caregiver, and explained the purpose of the visit. Rose Onyeagocha, Administrator, arrived at 11:08am. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden residents.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and back yard. The facility consists of six (6) and three (3) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 72 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 116.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/20/2022. Emergency Disaster Plan was last posted on 10/10/2019.

LPA reviewed four (4) staff files and three (3) of four were incomplete. LPA reviewed all four (4) resident files and all were incomplete.