Facility Evaluation Report

On 1/17/2024 at 1:45 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Caregiver Butch Jerza. Manager Telesha “Ava” Clarke arrived at approximately 2:10 PM.

The LPA inspected the facility inside and outside. All outdoor and indoor passageways were free of obstruction. Outside, the pond was inaccessible to residents with dementia. Inside, the temperature was measured at 74.7 degrees Fahrenheit. The LPA observed adequate lighting in all of the rooms for the comfort and safety of the residents. LPA observed 7 days of nonperishable and 2 days of perishable foods on hand. Sharps were stored inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition. Fire extinguisher was observed to be fully charged and last serviced on 3/16/2023.

The LPA reviewed the records of 3 residents.

2 Type-A citations and 1 Type-B were issued (for details refer to LIC809-D).

By 1/24/2024, Licensee will send updated forms to LPA:

· LIC308 - Designation of Facility Responsibility

Required Annual Inspection incomplete. LPA shall return unannounced to complete the inspection at a later date and time.

Exit interview conducted with Manager. A copy of this report provided via email to the Manager.