Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA met with Maria Constantin, Executive Director, and LPA explained the nature of the visit. Facility is licensed for 42 non-ambulatory residents. Facility has an approved hospice waiver for 15 residents. Facility is a memory care facility with approved delayed egress doors. There are residents in care on today’s visit. There are 5 residents on hospice during today's visit. This facility is a two story facility with exterior exits protected by delayed egress.

LPA Martinez along with the Executive Director toured the physical plant of both the facility. LPA observed residents involved in an activity as well as a posted activity schedule on both floors in the main common space. LPA inspected resident bedrooms which had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Several resident bathrooms on each floor were tested for water temperature and water temperature measured between 105.4 to 119.3 degrees F in tested bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA pushed the call buttons in bedrooms and bathrooms in various resident rooms and response times were between 1-2 minutes. LPA observed several residents who appeared clean, and happy. During the tour LPA inspected that medication is centrally stored in a safe locked location; facility has 2 medication rooms on each floor. LPA observed medication distribution is done with a medication cart. LPA inspected both locations and LPA observed and inspected medication carts that are used to dispense meds