Facility Evaluation Report

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA met with Administrator Erin Light and Director of Health Services Breanna Pritchard. Administrator's certificate expires 3/8/2023. LPA explained the reason for the visit. LPA and Administrator and Director of Health Services toured the facility. LPA observed a 2-day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the emergency food supply for the facility is kept secured in a storage room. The kitchen is clean and organized. LPA observed all refrigerators and freezers had temperature logs and were the proper temperature. LPA observed the resident rooms had the required furnishings. LPA observed all fire extinguishers are fully charged. LPA measured the hot water temperature in 2 resident rooms. Hot water measured 115.2 degrees Fahrenheit. LPA tested the emergency signal system. Staff responded to the call in one minute. LPA observed the outdoor patio area is spacious and has multiple shaded seating areas. No bodies of water observed. LPA observed the medication room is kept secured and all medications are stored inaccessible to residents. No obstacles or hazards observed inside or outside of the facility. LPA reviewed 2 staff files and 2 resident files. Fire sprinkler system was tested on 3/15/22. Last fire drill was conducted on 1/31/22. Facility has a mitigation plan that has been approved. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.