Facility Evaluation Report

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Kristine Mangente and was granted entry to the facility.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents. The current census is six (6) residents. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 112.2 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to the residents in care. There was a designated storage space for resident files and staff files. The medications are stored inside a closet near the living room inaccessible to the residents. During medication review, LPA found that the Resident’s R1, R2, R3, and R4 had medications that were removed out of their originally received prescription containers and were being stored in a plastic container cups. The facility will be issued a deficiency for not storing the resident’s medications in the original prescription containers. Non-perishable and perishable food supply is sufficient for the residents in care. The pool and spa in backyard is locked and inaccessible to the residents.