Facility Evaluation Report

On 09/19/2024 at 09:00 AM, Licensing Program Analysts (LPAs) Renese Howell-Small, and Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Howell-Small, and Brown met with a staff and was granted entry to the facility. Executive Director (ED) Kellie Smith was informed of the visit and met with LPAs Howell-Small, and Brown. At the time of the visit there were 106 residents present.

The facility is a one hundred fifty-seven (157) bedroom, one hundred fifty-seven (157) bathrooms with a kitchen/dining area, living room, theater room, library, laundry room. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred eighty (180) non-ambulatory residents and with an approved hospice waiver for fifteen (15) and the current census is 106 residents. LPAs Howell-Small and Brown were accompanied by ED Kellie Smith to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPAs Howell-Small, and Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean with a water temperature of 117 degrees Fahrenheit and appliances were operating appropriately. LPAs Howell-Small and Brown observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors, but no carbon monoxide detectors were observed at the facility. Deficiency will be issued. Fire extinguishers were also observed at the facility. Posters such as personal rights, ombudsman poster, labor laws, and the disaster plan were posted in a common area. However, LPAs Howell-Small and Brown did not observe the CCLD complaint poster. Technical Violation will be issued. During the visit ED Smith posted the required CCLD poster. ***Continuation in LIC809C ***