Facility Evaluation Report

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents of which one may be bedridden. Facility has an approved hospice waiver for 5 residents and the home currently has 6 residents, with 2 residents on hospice. Administrator (AD) Angela Talpos O'Connor arrived shortly to conduct facility tour. AD provided updated liability insurance that expires on 04/23/2026.

LPA along with AD toured the facility at 9:00 AM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of 6 resident bedrooms, living room, staff room, dining room, and kitchen as well as 4 bathrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 109.4 degrees F and 111.2 degrees F in all bathrooms checked. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducte d on 04/22/2025. Outside grounds were toured. There is shaded outdoor seating for residents. Exit gates are unlocked and operational . Walkways around the home were clear of hazards. First aid kit contained all required items including tweezers, scissors and thermometer. LPA observed the emergency food and water supply.