Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual/legal-non compliance visit at 9:30 a.m. This annual had an emphasis on infection control practices and procedures. The LPA met with Administrator Blake Forbes and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: There has been an ongoing issue with the facility's dishwasher; however there is another dishwasher on site in operable condition. The facility has repaired and attempted to replace the dishwasher on several occasions. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The client bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms are clean, sanitary and in operating condition. The common bathroom was observed with appropriate signs and stocked with paper towels. Signs promoting good hand hygiene were observed. Water temperature measured at 118.2 F.

COMMON SPACES: The LPA observed the living room, dining room, Great Room, laundry facilities and Gym on the first floor; and the library and movie theater on the second floor. At the time of the visit, furniture, walls, and flooring were observed to be in good condition. Fireplaces are inaccessible. Throughout today’s visit, the LPA observed appropriate signs in common areas that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. There is sanitizer available throughout the facility. At 10:15 a.m., the smoke detectors and carbon monoxide detectors were tested and were operable.

The backyard has a covered outdoor area equipped with furniture for client use. The in-ground pool and hot tub are appropriately fenced and locked. The garage is attached to the facility and locked. The detached pool house is designated for therapeutic services and is inaccessible to clients unless supervised by staff.