Facility Evaluation Report

On 12/21/2023 at 09:00 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff, was granted entry to the facility. At the time of the visit there were three (3) staff present, and five (5) residents present. Licensee/Administrator Linda Thomas was contacted and arrived during the visit.

The facility is a five (5) bedroom, three (3) and half bathroom home with a kitchen/dining area, living room and attached two (2) car garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which (6) can be non-ambulatory residents and six (6) may be bedridden resident. The facility has six (6) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Licensee/Administrator Linda Thomas (S1) 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 (CCL). LPA Brown observed no obstructions to outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown 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 Brown observed grab bars and non-skid mat or strips in the resident bathrooms. There was a designated storage space for resident/staff files. The facility has a locked medication room where residents medications are stored. Also, LPA Brown observed a complete first aid kit maintained and readily available at the facility and first aid books. To add to that, LPA Brown measured and observed the water temperatures in the bathroom to be at 112 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, infection control plan, Labor Laws and the disaster plan were posted in a common area.