Facility Evaluation Report

On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #18-AS-20220503084418. During today's inspection, LPA Colvin observed the following deficiencies:

Accessible Chemicals: LPA Colvin observed the door for the laundry room and the garage to be propped open with a bottle of bleach. LPA Colvin observed other chemicals on the ground between the washing machine and dryer. Deficiency cited.

Living Accommodations: During LPA Colvin's inspection of the facility. LPA Colvin observed that one of the resident bedrooms (the only single bed resident room) to not have a door. Instead, LPA Colvin observed a curtain hung up across the doorway to provide some element of privacy to the resident (R1). When LPA Colvin inquired about the missing door, Licensee/Administrator Gertrude "Trudy" Okoro stated that it was removed in order to be able to use a Hoyer Lift for the resident. Deficiency cited.

Alterations to Building: During today's inspection, LPA Colvin observed a hidden office/bedroom adjoining the facility dining room. In this room, LPA Colvin observed a bed, which the Licensee/Administrator stated was used sometimes by her and sometimes by her husband. LPA Colvin inquired about when the changes were made to add this room, but the Licensee/Administrator was unsure. LPA Colvin requested a copy of the facility's building sketch, which was provided. LPA Colvin pointed out to the Licensee/Administrator that this room was not noted on the sketch, and therefore, must have come after the facility was licensed. There is also no note of the room in the Pre-Licensing inspection done on 11/28/18. Community Care Licensing (CCL) was not notified of the change and updated facility sketch was not provided to CCL to update the facility's file. Deficiency cited. LPA Colvin additionally inquired about if the facility obtained a building permit for the room .