Facility Evaluation Report

Licensing Program Analysts (LPAs) Hanna Gough and Ruth Martinez made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs met with Administrator (AD) Ephantus Warui and discussed the purpose of the visit. The facility currently has 147 residents in care.

The facility is a two story building with resident apartments, bathrooms, activity room, dining room, medication room, memory care unit and staff offices. LPAs observed the memory care unit to be on the first floor with delayed egress doors that were found to be operational. LPAs observed the memory care unit to have resident apartments and an activity room/dining room with access to an outdoor shaded seating area. LPAs observed all resident bedrooms had the required components and furnishings. LPAs observed a hole in the wall of room 120 where exposed wires were observed. LPAs observed the bathrooms to have toilet paper, paper towels and non slip mats in the shower. LPAs tested the water to be between 106.7 to 119.1 degrees Fahrenheit. LPAs observed the laundry rooms to be locked and made inaccessible to residents in care. LPAs observed the extra linens to be on the second floor. LPAs observed toxins and chemicals to be in a locked room on the first floor. LPAs observed the emergency food and water supply to be in a closet on the first floor. LPAs observed the medication room on the first floor to be locked and made inaccessible to residents in care. LPAs observed the facility to have a completed first aid kit in the medication room. LPAs observed the kitchen to be clean and free of vermin. LPAs observed all appliances to be operational. LPAs observed the knives to be in the kitchen and made inaccessible to residents in care. LPAs observed the activities being conducted in the activity room during the duration of the inspection. LPAs observed the pull chord system to be operational with an immediate verbal response from the front desk and a 2 minute physical response time from care staff. LPAs observed an outdoor shaded seating area in the middle of the facility for resident enjoyment. Continue on LIC 809C