Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen conducted an unannounced required 1-Yr. annual Infection Control inspection of this facility and met with Administrator Elvira Gazal. Currently there are 5 residents in care 2 are receiving hospice care and 4 residents with dementia diagnosis in care.

LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. Some residents have call buttons which sound in kitchen area. The amount of fresh and nonperishable foods is within regulation. Toxins are stored in locked garage and locked hallway closet. Water temperature measured at 110.6 degrees F and 113 degrees F which is within regulation between 105 and 120 degrees F at bathroom faucets accessible to residents in care. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. Fire extinguisher inspected was charged and dated 1/6/2023. Smoke detectors and Carbon Monoxide detectors were tested and found to be in working order. Facility has fire pull station located by front door. Medication is centrally stored and secure in kitchen along with small refrigerator with lock for medication (hospice kit). Disaster Drills had been conducted every 3 months the last being 2/1/2023.

Facility has submitted a mitigation program plan and infection control plan. In addition, facility has a designated area for visitors which are being allowed for visits. Residents also have available telephone calls when contacting with family members and others. Staff had all PPE training required on file and have received N-95 fit testing.