Facility Evaluation Report

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit.

The facility is a single level structure and licensed for six residents (6 non-ambulatory) and has a hospice waiver for six. As of today, the facility has six residents admitted. All residents were present during the visit, and one left for their day program shortly after the visit began. There is a total of 4 bedrooms (3 resident & 1 staff) and 2 bathrooms areas (1 Resident & 1 Staff). There’s a living room space, a dining space, backyard and an attached garage. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water was measured in the range of 110.6 and 114.8 degrees F. Kitchen: 4 of 5 burners are operational on the gas stove. The center burner will not light unassisted. No sharps or cleaning solutions are stored in the kitchen. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed in the kitchen. Additional food and water was observed in the garage.

Resident & Staff Files : Resident and staff files are stored in the locked filing cabinet in the kitchen.

File Review: Three resident files were reviewed during the visit, and three staff files were reviewed.

Medications/First-Aid Kit: Resident medications are stored in the locked medication cabinet in the kitchen. A first aid kit with all the required elements was observed in a cabinet in the kitchen above the printer.

Medication Review: Three resident medications were reviewed during the visit. No discrepancies were observed. Medication is being administered as prescribed.