Facility Evaluation Report

01/02/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 6 clients in care. LPA was greeted by Administrator, Ann Gougher.

At approximately 1:30pm, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 109.2 and 106.3 which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 04/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Sharps are located in a kitchen drawer and were secured. Toxins are stored in the laundry room and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. LPA reviewed client cash resources.

LPA conducted a review of 4 client records. All records had the required documentation. LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

No deficiencies cited during today's inspection . Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

Infection Control Plan (review, update if needed)

Emergency Disaster Plan (review, update if needed)

Exit interview conducted with Administrator and a copy of this report was provided .