Facility Evaluation Report

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Care staff Brennan Williams during today's inspection. LPA ensured they applied hand sanitizer before entering the facility.

LPA toured facility to ensure health and safety of clients in care. LPA toured 3 client rooms, 2 bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 2 of 3 resident files and 2 staff files. LPA reviewed medications of two residents comparing with physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA reviewed client P& I records and reviewed receipts.

LPA checked water temperature and observed water at 135 degrees. Deficiencies cited on 809-D. Appeal rights provided.