Facility Evaluation Report

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Administrator Designee Lydia Olila and explained the reason for the visit. At approximately 09:15 am, with the assistance of Administrator Designee, LPA took a tour of the physical plant. Required postings were observed in the entry area. The fire extinguisher is located in the dining area. .LPA tested the smoke alarms and found that they function properly; however, the carbon monoxide detector was not functioning properly. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility, properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets.

Bedrooms: There were four (4) bedrooms designated for residents' use. Two (2) bedrooms are designated for private use, and two (2) rooms are shared. All four bedrooms in use by residents were properly furnished with appropriate beddings and linens and with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. The hot water temperature from the main bathroom sink was measured at 115.2 degrees Fahrenheit. No cleaning supplies or hazardous items were present in the main bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards.The gates at both sides of the home were checked to ensure no locks were installed, and that exits and passageways were clear for emergency evacuation. The laundry room: The Laundry door is locked, and thus, chemical hazards are inaccessible to residents. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. LPA observed that R1 has incomplete physician report and R2 has no updated Physician Report. In addition, R2 and R3 have no hospice care plan. (Continue on 809C)