Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by caregivers and explained the reason for the visit. Administrator (AD) Marilou Leal arrived shortly to assist with the visit. Facility is licensed for four non-ambulatory residents, two ambulatory residents with a hospice waiver for one. Currently there are five residents.

LPA Tea reviewed five resident files and three staff files. Resident files and staff files contained all required documentation. Annual staff training is still being completed at the time of visit. AD Leal’s administrator certificate expires on January 30, 2027.

LPA Tea along with the Administrator toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 5 resident bedrooms, 1 caregiver room, 3 bathrooms, living room, dining room, kitchen, and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. The glass mirror in the main bathroom has cracks. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured around 118.4 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards; doorways were free of obstructions. First aid kit had the required elements including dressing, bandages, thermometer, tweezers and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps are locked and secured in a kitchen cabinet. LPA observed toxin substances