Facility Evaluation Report

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Assistant Administrator Mary Gonzalez. The facility's license shows a maximum capacity of one hundred twenty-five (125) non-ambulatory residents. Hospice waiver for ten (10). During today’s inspection there were ninety-one (91) residents in care.

LPA with Assistant Administrator Gonzalez toured the interior and exterior of the facility and inspected a sample of rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were stored in locked areas. LPA observed multiple prescription labels with writing. Interviews revealed that facility staff write the start date of the medications on the prescription labels. No pools or bodies of water exist on the premises. Per Assistant Administrator Gonzalez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas.