Facility Evaluation Report

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the annual inspection. LPA Allen, met with Svetlana Dagala- Caregiver and she was informed of the purpose of the visit.

Facility is licensed to serve six (6) ambulatory residents and an approved hospice waiver for three (3) residents. Two (2) of the residents may be non-ambulatory. Currently there is no one on hospice and One (1) resident is receiving home health services. The facility does not handle any of the residents’ money.

This home is a single story home consisting of: four (4) bedrooms, three (3) bathrooms, sofa and kitchenette. There is an adjacent enclosed patio/activity room area, laundry room (located in the attached garage) and an outdoor shaded patio area.

At 1:00 PM, LPA Allen, toured the resident bedrooms which had the required furniture, bed linens and closet/drawer space to accommodate each resident. The bathrooms appeared to be in good condition and operational. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 105- 119.F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

At 2:00 PM, LPA Allen, reviewed two (2) clients’ files for admission agreements, updated physician reports, and needs and services plan which appeared to be up to date.