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 non-ambulatory residents, and has a hospice waiver for four. As of today, the facility has four residents admitted and 4 of 5 residents were present during the visit. There’s a total of 5 bedrooms of which 4 bedrooms are for the residents and one bedrooms is for staff. There are two restrooms available. There’s a living room space, a dining space and the attached garage as been converted into an ADU. 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 measured in between 113 – 115.5 degrees F. Kitchen: All burners and the warmer were operational on the gas stove. Sharps are kept in a locked cabinet under the sink. Cleaning solutions and dish soaps are stored in the kitchen directly below the sink. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed. An additional refrigerator was observed, and an additional pantry areas well stocked with nonperishable items.

Client & Staff Files : Resident and staff files stored in cabinets behind the dining table.

File Review: 3 of 5 resident files were reviewed during the visit, and three staff files were reviewed.

Medications/First-Aid Kit: Resident medications are stored in a medication closet cabinet across from the kitchen.