Facility Evaluation Report

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by facility Administrator (AD) Annamarie Tomill. LPA Haley explained the reason for the visit, and was temperature checked upon entering the facility. AD Tomill has a current Administrators certificate that expires 04/02/23.

At 2:30 PM LPA Haley and AD Tomill began the inspection at the entrance of the facility. There was four clients present during the visit. A screening station with a thermometer, surgical mask, and hand sanitizer was observed right next to the main entrance.

Clients bedrooms were clean, organized, and had all necessary requirements: night stand, chair, lamp and storage space. Client bathrooms were clean and organized. Hot water temperature was measured at 108.8 degrees Fahrenheit in bathroom #1 and 107.9 degrees Fahrenheit in bathroom #2. In the hallway near client bedrooms and bathroom #2, LPA observed a locked hallway cabinet with cleaning supplies on one side and clean sheets on the other side of the cabinet. Below the cabinet, boxes of files were observed.

All required posting were observed on the walls in the living room and outside the main entrance. A file cabinet with client and staff files was observed next to bathroom #1. In the living room near the kitchen LPA observed a locked medication cabinet. Inside the medication cabinet were three first aid kits with all the required items. Across from the medication cabinet was a shelf with several files, folders, a cubby with staff items, and printer.

In the kitchen, all knives and sharp objects were locked in a drawer next to the stove. All hazardous cleaning chemicals were locked under the sink. A 2 day supply of perishable food items and a 7 day supply of non-perishable food items was observed. LPA observed a fully charged fire extinguisher on the floor where the kitchen borders the living room/dining room. Three of four burners on the stove were operational. LPA advised AD Tomill of the importance of the facility being in good repair at all times.