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 Staff Melati Wulansari. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. Hospice waiver for six (6). During today’s inspection there were four (4) residents in care. Administrator Kristine Mangente arrived later during the visit.

LPA with Administrator Mangente toured the interior and exterior of the facility and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Windows, screens, toilets, and showers were in working order. LPA observed that the glass on the backdoor in Bedroom #1 was shattered on the first pane, with webs of cracks along its surface. 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 labeled, as required, and stored in locked areas. The pool on the premises was gated and locked as required. Per Administrator Mangente, 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.