Facility Evaluation Report

Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Administrator Maxine Kniazeff and explained the reason for the visit.

LPA Frank toured the facility. There are 3 residents residing in the facility and no active COVID-19 cases. LPA observed 6 of 6 residents on site appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all confirmed food supply: 2 day supply of perishables and 7 day supply of non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet.

LPA observed Facility’s physical plant, hallways appears to be clean and free of debris, free of odor. Sufficient lighting observed throughout the facility. No bodies of water, weapons or ammunition on premises. Smoke detectors and carbon monoxide detector were tested and are operational. Fire extinguishers were fully charged. Fire drill was conducted on 6/5/22. Facility stove, oven, microwave, refrigerator, washer and dryer are clean and operational. LPA observe the facility to be clean and in good repair.

LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808)

Mitigation Plan and 3) Current Liability Insurance, LIC 9282 infection Control Plan, Designation of Administrative Responsibility (LIC308) and

Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.

This report was discussed with the facility representative and a copy was provided.