Facility Evaluation Report

Licensing Program Analyst LPA Shawna Doucette arrived at the facility unannounced and conducted an Annual Inspection on this date. LPA contacted Administrator Cheryl McCraw via telephone, who responded to the facility to assist with the visit. Staff Kahiya Brewster granted LPA into the facility.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen toured, appeared clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Knives are locked in the kitchen drawer.

Resident rooms checked and found to be clean. Hot water measured at 114.2 F degrees F in bathroom. Bathroom tub was rusted. LPA took photos. Facility was set at 69 F.

Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 06/10/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility did not have documentation of current emergency drills completed. Facility has a pull station fire alarm and a sprinkler system. Sprinkler system has not been serviced annually to ensure it is operating. All cleaning supplies are locked in a cabinet in the in the laundry room.

Staff files were reviewed. Staff have current first aid and CPR on file. Resident files were reviewed with current IPP's.

Refer to 809D. Civil Penalties were issued for fire clearance.

An exit interview was conducted with Administrator and a copy of this report was provided along with plans of correction and appeal rights.