Facility Evaluation Report

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced required annual visit and was greeted by two staff members. The Licensee, Mary Ann De Lima arrived at 10:40 am. The facility is licensed to serve six residents of which six may be non-ambulatory and one may be bedridden in any of the bedrooms and there is a hospice waiver for six.

LPA Spaeth reviewed the residents files at 10:30 am until 11:30 am. LPA reviewed staff files at 11:45 am until 12:15 pm. LPA observed two staff members' CPR/First Aid training had expired.

LPA Spaeth and the Administrator toured the facility at 12:00 pm until 12:30 pm. LPA Spaeth observed the facility was neat and clean.

Kitchen – LPA observed a seven-day supply of non-perishable food and a two day supply of perishable food items. LPA observed the cleaning supplies were securely locked underneath the kitchen sink and the knives were locked in a kitchen drawer. The medications are locked in a kitchen cabinet and LPA also observed the first aid kit. A fire extinguisher is also located in the kitchen area.