Facility Evaluation Report

On 11/20/2024 at 01:18 PM, 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 and was granted entry to the facility. Licensee/Administrator Chrystal Condit was informed of the visit and arrived at the facility during the visit. At the time of the visit there were two (2) staff present, and three (3) residents present.

The facility is a three (3) bedroom, two (2) bathroom home with a kitchen/dining area, living room/activity room, laundry room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents of which two (2) may be bedridden. The facility’s approved for four (4) hospice waiver. The current census is three (3) residents. LPA Brown was accompanied by Licensee/Administrator Condit 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 75 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the bathroom to be at 107 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguisher was also observed at the facility. Posters such as personal rights, the CCLD complaint poster, and the disaster plan were posted in a common area. LPA Brown observed Resident #2 (R2) has half bed rail and per interview and documents review, R2 does not have a written order from R2 physician indicating the need for half bed rail for mobility. Deficiency will be issued. ***Continuation in LIC809C ***