Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit to the facility to complete the required annual inspection. LPA Tea was greeted and granted entry by caregiver staff, and explained the purpose of the visit. Administrator (AD) Carmen Achim arrived shortly to assist with the inspection.The facility is licensed to serve six non-ambulatory residents and has an approved hospice waiver for three residents. At the time of the visit, the facility was operating at full capacity with six residents in care and two residents were receiving hospice services.

LPA Tea reviewed six resident files and two staff files. During the file review, discrepancies were identified. One resident was missing required consent forms, and another resident’s appraisal documentation was incomplete. Staff records indicated that health screening forms were not updated to reflect current health status, and personnel record forms were missing. The Administrator’s certificate is valid through December 1, 2027.

LPA Tea, accompanied by staff, conducted a tour of the facility, including the physical plant, food service areas, and first aid supplies. The home consists of six resident bedrooms, one staff room, four full bathrooms, four half bathrooms, a living room, family room, dining room, kitchen, laundry room, and an attached garage. Smoke detectors and carbon monoxide detectors were observed to be operational in both common areas and resident bedrooms.

Resident bedrooms were adequately furnished with appropriate bedding, linens, and sufficient storage space (Annual Inspection continued on LIC809C)