Facility Evaluation Report

Licensing Program Analysts (LPAs) Christine Yee and Erica Mosley conducted a joint unannounced required Annual Inspection using the CARE Inspection Tool and met with Aaron Feingold, Designated Responsible Staff. Also participating in today's visit was Evelina Papazyn, Consultant. The reason for today's visit was explained.

The facility is a 3 storey residential building consisting of 30 bedrooms, a commercial kitchen, dining room, television room, lounge and a staff break room on the first floor. The second floor has 35 bedrooms, dining room, library and television room. 16 bedrooms out of the 35 bedrooms are designated for the dementia unit. The third floor has 36 bedrooms. The facility is fire cleared for 63 Ambulatory, 112 Non-ambulatory and 20 bedridden residents. Delayed egress is approved for the dementia unit.

On today's visit, all 12 domains of the CARE Inspection Tool was reviewed, 8 staff and 8 resident files were reviewed and a tour of the physical plant, inside and outside were toured. Medications were also reviewed beginning at 3:00pm.The following rooms were inspected on today's visit: Room #s 101, #108, #124, #206, #212, #221, #234, #301, #316 and #335.

Per tour of the resident rooms inspected, the rooms contained the required furniture. The bathrooms all contained a toilet, shower, grab bars, shower chair and a slip resistant mat. The water temperature were tested in the bathrooms and the water temperature in some of the bathrooms met Title 22 requirements and some did not have any hot water as the plumbers were still working on the plumbing needed to correct the