Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 11:28 AM. LPA met with Administrator Mark Samuel. Entrance interview conducted and the reason for the visit was explained.

RECORD REVIEW: Record review began at 11:32 AM. Staff records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, and fingerprint clearance. Nine (9) staff files were reviewed. All staff files contained the required documents and trainings. No deficiencies were observed during record review.

MEDICATION REVIEW/CASH RESOURCE REVIEW: Medication review began at 12:19 PM. Medications for five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Cash resource records were reviewed for five (5) clients, the facility does not store client money. All cash resource records observed were documented properly. No deficiencies were observed during cash resource review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 06/18/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administration. CONTINUED ON LIC 809C.