Facility Evaluation Report

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Alan Shelley about visit. However, due to AD being out of town, AD provided consent for House Manager (HM) Madison Shelley to receive and sign report. As of 10/14/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility. LPA observed the Administrator's Certificate for Alan Shelley which expires on 3/24/23.

LPA De Perio toured the interior and exterior portions of the facility with HM Shelley. The facility is a single level structure and is licensed for 6 non-ambulatory residents of which 0 may be bedridden and a hospice waiver for 4. For this visit, there are a total of 6 residents in care of which 2 are on hospice and 0 bedridden. There are a total of 7 bedrooms, of which 6 are private resident rooms, 0 shared and 1 bedroom for staff. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms in the facility of which were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 113.2 degrees Fahrenheit.