Facility Evaluation Report

On 12/09/2024 at 9:30 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Required Annual Inspection at the facility mentioned above. LPA was greeted by staff #1 (S1) who granted access. S1 requested LPA wash hands before continuing into the home. S1 contacted the administrator. House manager Lena Johnson met LPA at approximately 9:43 a.m. LPA explained the reason for the visit. The facility is licensed for three (3) ambulatory, three (3) non ambulatory of which one (1) may be bedridden with a total capacity of six (6) residents. Facility has a Hospice wavier for two (2). The inspection tool was used to complete the visit.

A physical tour was conducted at approximately 9:45 a.m. along with the house manager and LPA observed the following:

Entrance: LPA observed proper postings along a wall by the first living room and dining table. LPA observed hand sanitizer and masks were available. The fire extinguisher was observed by the front door with a purchased date of on 12/05/2024, fully charged. A second was by the kitchen with same purchase date.

Common Areas: These include the dining area, and living rooms. All common areas were observed well lit, clean and clear of clutter. Furniture appeared clean and in good repair. There is a fire place properly secured with a screen.

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Knives are kept locked in a kitchen drawer inaccessible to residents. LPA observed there to be sufficient supply of 7-day non-perishable foods and 2-day perishable foods; properly stored.

Bedrooms: There are four (4) bedrooms designated for resident use. One (1) out of four (4) bedrooms is a shared. Continued to LIC809-C)