Facility Evaluation Report

Licensing Program Analyst Shawna Doucette (LPA) arrived at the facility unannounced to conduct a Required Annual inspection. LPA was met by House Supervisor Angie Gonzalez and House Supervisor Joy Mackey and was granted entry into the facility. LPA spoke with Administrator Rebecca Wood who gave permission for House Supervisor to handle the visit.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Facility was set at 70 F. 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. Resident rooms checked. LPA observed an adequate supply of linen. Hot water measured at 118.9 degrees F. Exterior tour conducted, all exits open and free of obstructions.

Fire extinguisher serviced on 1/17/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted 4/01/2024. Cleaning supplies were not locked and secured in a cabinet in the garage. Facility did not have a lock for the cabinet. Facility staff purchased a lock and the deficiency was cleared during the visit. Medications were locked on a cabinet in the kitchen.

Medications were reviewed. Staff files and Resident files were reviewed. Staff have CPR/First aid training.

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