Facility Evaluation Report

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with Administrator Nancy Mandic and Licensee Deborah Herbert. The purpose of the visit was explained. Facility is licensed to serve 66 residents over 59 years old of which 26 may be non-ambulatory and 40 may be bedridden. Facility is approved to retain/accept fifteen (15) hospice residents. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. Facility has submitted a mitigation plan and the plan has been approved.

Facility is a campus area with different cottage buildings which are identify as the Ranch House, The Hearth and The Stewart Cottage. Each building has a fire sprinkle system and smoke detectors which are hard wired and interconnected (w/back-up battery) and were observed in the hallways and bedrooms. There are alarms on all exterior doors, and they were tested and operational at the time of visit. The fire extinguishes observed to be fully charged and meets regulations.

A large body of water / pool area was observed at the facility which was gated and locked. All indoor and outdoor passageways are free of obstruction. Facility has several visiting areas indoor and outdoor. Outdoor areas are covered and have tables and chairs to accommodate the residents during visitations and outdoor activities. One entrance being utilized for each building at the facility, all required posters were posted at the entrance. Screening area is located in the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit.