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 has two level structure and licensed for 80 non-ambulatory residents and has a hospice waiver for 15. The facility currently has 72 residents and 70 residents were present during the visit. The facility consist of Assisted Living and Memory Care. Bedrooms: Seven random resident bedrooms/restrooms were inspected and all had 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 115.1 – 118 degrees F. Kitchen/Food Service: A food supply that meets regulation requirements was observed. The facility receives four shipments from two different carriers a week. Food temperature logs were observed, and Freezer/Refrigerator logs were observed. Temperature logs are updated daily. Food temperature logs are recorded during each meal.

Client & Staff Files : Resident and staff files are located on the first floor in the business office and the Executive Directors office.

File Review: Seven resident files and seven staff files were reviewed during the inspection.

Medications/First-Aid Kit: Resident medications are stored in the medication carts and stored on the second floor in the wellness room. A first aid kit with all the required elements was observed mounted on the wall in the wellness room near the medication carts.