Facility Evaluation Report

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Program Manager Cherita Beard and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin observed the facility to be a comfortable temperature of 74 degrees. LPA Colvin measured the hot water in the occupied resident bedroom and observed it to be measuring at 129.2 degrees. Deficiency cited. LPA Colvin did not observe any obstructions to emergency exits or hallways/walkways. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives and dangerous chemicals were locked in the staff office. The facility has an in-ground pool in the backyard which LPA Colvin observed to be covered.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 ambulatory residents.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a designated medication closet and is inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. LPA Colvin additionally reviewed medications for all residents and did not observe any concerns during today's inspection.