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 resident (5 non-ambulatory), of which one may be bedridden. As of today, the facility has three residents admitted to the facility. All of the residents were present during the visit. There’s a total of 5 bedrooms (4 resident & 1 staff) and 2 bathrooms areas for residents. 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 at 116.6 degrees F in both restrooms. Kitchen: 5 of 5 burners are operational on the gas stove. Sharps are kept locked in a cabinet under the counter. Cleaning chemicals are stored in a locked cabinet below the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed.

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

File Review: 3 of 3 resident files were reviewed during the visit, and 3 staff files were reviewed.

Medications/First-Aid Kit: Resident medications are stored in the locked medication cabinet in the kitchen. A first aid kit was also observed mounted on the wall in the dining room.

Medication Review: 3 of 3 resident medications were reviewed during the visit.