Facility Evaluation Report

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Cherie Wood and explained the reason for the visit.

The facility is licensed to serve 6 residents age 60 and over of which 2 may be non-ambulatory and 2 may be bedridden in room #5 with a hospice waiver for 4. The facility is located in a residential area and consist of a single home with (4) resident bedrooms, (3) bathrooms, (1) staff bedroom, a living room, a dining room, a kitchen, a laundry area, an attached garage a front yard, and a back yard.

The following domains were reviewed during this visit:

Infection Control : Facility maintains a copy of the infection control plan. All staff have a TB clearance.

Operational Requirements: Facility maintains a plan of operation, fire clearance. Facility is operating within the limitations of their license. They currently don't any residents under hospice care, home health, or bedridden. A current liability insurance was observed and a copy was obtained.

Physical Plant/Environmental Safety: LPA toured the facility with Cherie Wood and observed the following. Facility was observed in good repair. Living room and dining room were observed with furniture and in good repair. Kitchen was observed clean. Cleaning supplies and sharps are maintained in a locked drawer, sharps magnetic lock was observed slightly out of place. Refrigerator/freezer and pantry were observed. Medication cabinet is located across from the kitchen. Four (4) resident rooms were observed with sufficient lighting, required furniture and bedding supplies. Half bed rails were observed in Resident #1,2,3, and 5 beds, here is no physician's request on file. Three (3) bathrooms were observed in good repair and clean. Water temperature was tested in each bathroom sink and tested between 109.0-113.3 degrees F., which is within the required 105-120 degrees F. A fire extinguisher was observed. Carbon Monoxide/Smoke detectors were tested and are in working condition. (CONTINUED ON LIC 809C)