Facility Evaluation Report

At approximately 12:00 p.m. on 08/25/2022, Licensing Program Manager (LPM) Cassandra Harris conducted an announced prelicensing visit. LPM met with Administrator and disclosed the reason for the visit. At approximately 12:40 p.m. Licensing Program Analyst (LPA) Nicholas Reed joined the inspection. LPA, LPM, and Administrator toured the facility inside and out.

It is a two story facility with 9 bedrooms, 9 bathrooms, pantries, common areas, lactation room, medication room and outdoor areas. It has an approved fire clearance for 16 residents, of which 2 may be non-ambulatory. The facility uses surveillance cameras inside.

LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer and a digital visitor log. The visitor log tracked contact information, temperature, symptoms, and vaccination status. Postings included grievance procedures, personal rights, confidential complaint contacts, house rules, activity schedule, and facility menu. Walls, floors, ceilings, windows, and blinds were clean and in good repair. At approximately 12:30 p.m. LPM tested the smoke detectors to be operational. At 12:50 p.m. LPA measured the room temperature to be 75 degrees Fahrenheit. At 12:55 p.m. LPM tested the carbon monoxide detector to be operational, and LPA measured the water in a hallway bathroom to be 109 degrees Fahrenheit. Past the screening station were an intake office and a mud room. The mud room contained a shower and a Zapp machine for sanitation. Janitor closets with cleaning supplies on the first and second floor were locked. Extra linens, client lockers, activities, board games, and hygiene supplies were located in storage closets on the first and second floor. The facility has emergency water supplies and emergency food supplies in the first floor pantry. The pantry contained sufficient supplies of perishable and non-perishable food. The pantry also contained two refrigerators, two freezers, cooking tops, and a retherm unit. At 12:59 p.m. LPA measured a refrigerator and freezer temperatures to be 37.2 degrees Fahrenheit and -2.2 degrees Fahrenheit, respectively. Sharps were locked in a lockbox by the sink. The dining room outside of the pantry contained utensils, coffee machine, and snacks.