Facility Evaluation Report

At approximately 10:00 a.m. on 03/21/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced prelicensing visit. LPA met with the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out from 10:15 a.m. to 11:30 a.m. No immediate health or safety concerns were observed.

The facility is a three story building with activity rooms, business offices, lounge areas, kitchen, laundry room, three dining rooms and an outdoor area. It has an approved fire clearance for 126 nonambulatory residents, of which 50 may be bedridden.

Upon entry, LPA observed a reception area with a visitor and resident sign-in sheet. An activity room was located near the main entrance. Residents were observed exercising with staff assistance. Business offices were also located near the main entrance. The facility had single and double occupancy rooms on all three floors. Elevators and stairwells were in good condition and free of hazards. Emergency evacuation chairs were observed at the tops of each stairwell. Fire sprinklers were observed in resident rooms and throughout the facility.

LPA and Administrator toured Room #111 on the first floor and Room #221 on the second floor. The bedrooms were in good condition and each contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. The bathrooms contained soap, paper towels, grab bars near the toilet and shower, and non-skid strips in the shower At 10:20 a.m. LPA tested the pull cord system in Room #111 to be operational. The pull cord alerted staff pagers, and staff responded promptly. At 10:24 a.m. and 10:43 a.m. LPA measured the hot water temperatures in the rooms to be 109 degrees Fahrenheit and 117 degrees Fahrenheit, respectively. At 10:26 a.m. LPA tested the smoke detector in Room #111 to be operational.