Facility Evaluation Report

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Zenia Shah and explained the purpose of the visit. Administrator certificate is current. Facility has a Hospice waiver for 5 residents.

At approximately 9:00AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and outdoor areas. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen equipment was clean and in good repair. Dishware appeared to be stored in a sanitary manner. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature. Facility has required supply of perishable and non-perishable food. Emergency water was present to ensure facility can be self-sufficient for 72 hours. Facility has a generator to supply power in an emergency. Emergency lighting devices were present. First aid kit was present. No pools/bodies of water are on the premises. Facility has been conducting Emergency drills every 3 months. LPA inspected the doors in the memory care section of the building. LPA observed both internal doors were equipped with delayed egress devices that allow the door to be opened with 15 seconds of constant pressure. LPA was informed there were still parts on order before the doors are complete, but should be installed by the end of the month. LPA requested confirmation when the installation is complete. At this time, the doors are operational but are still opened with key code access. Doors have signs alerting the individual of the 15 second delay.