Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Fuller made an unannounced visit to the facility to conduct the required annual inspection. LPA entered the facility and waited for staff at the front counter and observed the windows and doors to the reception office to be unlocked leaving the medication on the tables and in the fridges accessible. LPA met with Administrator (AD) Gil Agas and discussed the purpose of the visit.

The facility is a two-story building that consists of 30 resident bedrooms on each floor with shared Jack and Jill bathrooms. There are communal shower rooms, an activity area, dining room, kitchen, staff office spaces, laundry room and outdoor courtyard patio in the middle of the building. LPA observed the resident rooms to have all the required components and furnishings. LPA observed the bathrooms to have toilet paper and paper towels. The water tested between 105 and 120 degrees Fahrenheit. LPA observed shower rooms with multiple showers for resident use. All were equipped with non slip mats. LPA observed the old medication room to be used as storage with medications on the back shelves. The room was found to be unlocked and accessible to residents. Staff promptly locked it after discovery. LPA observed a locked housekeeping room where toxins and chemicals are stored. LPA observed the kitchen to be clean and free of vermin. A two day perishable and seven day non perishable food supply was on hand. The emergency food and water supply was observed to be in the kitchen pantry. The knives are in a kitchen drawer in the middle island with the kitchen door and window being able to lock after kitchen staff leave making them inaccessible to residents. All appliances were found to be operational. LPA observed the dining room with lunch being served to residents during the inspection along with activities being conducted. The activities area takes up the back of the dining room. LPA observed the medication to be stored in the reception office with the medication carts being locked.