Facility Evaluation Report

Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility, LPA met with Alexander Stott (Administrator) and explained the purpose of the visit. The facility is licensed to serve: 3 AMBULATORY AND 3 NON-AMBULATORY.

LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools which contain the following domains: Infection Control, Physical Plant & Environment Safety, Operational Requirements, Staffing, Personnel Reports-Training, Client Rights - Information, Client Records-Incident Report, Food Services, Health Related Services, Incidental Medical Services, Disaster Preparedness, Emergency Intervention.

A tour of the two-story facility includes: Living room, kitchen, dining area, office, 6 client bedrooms, 7 bathrooms, exercise area and laundry room.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. All outdoor and indoor passageways are free of obstruction. There are no pools or large bodies of water on the premises. There are no firearms on the premises and other dangerous weapons such as knives are locked in the kitchen cabinet. Disinfectants, cleaning solutions, poisons are inaccessible to clients. A comfortable temperature for clients is maintained. Lamps or lights in all rooms to ensure the comfort and safety were observed. Hot water temperature measured between 105 degrees F and 120 degrees F. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products are readily available. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Freezers and refrigerators are clean, and maintain temperatures. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. A plan to ensure that clients receive assistance in meeting their medical and dental needs were observed. Continue to LIC809C...