Facility Evaluation Report

On 11/20/2024, Licensing Program Analysts (LPAs), Andrei Castillo and Seo Jeon arrived at the facility unannounced to conduct the required annual inspection. Upon entry, LPAs were greeted by Executive Director, Jack Poyfair and informed him of the purpose of the visit. At the time of the visit, there were ten staff members and forty seven residents present. LPA conducted a tour of the facility with the Executive Director, reviewed facility documents and conducted interviews. The following is a summary of the visit:

Facility Overview: The facility has two buildings with total thirty bedrooms and eighteen bathrooms. Resident bedrooms had the required bedding, furniture, and lighting. Facility sketch, exit routes, personal rights, “If you See Something, Say Something,” LTC Ombudsman, complaint information and emergency phone numbers were observed posted in the facility. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care.

Infection Control: There were hand hygiene and hand washing stations, and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: Floors, windows, and doors were clean and well-maintained. Furniture and fixtures were in good condition. The outdoor areas were free of hazards and have shaded areas with outdoor furnitures. Laundry equipments were in good working condition. LPA observed fully charged fire extinguishers. Disinfectants, cleaning solutions, and sharp and dangerous objects were securely locked and inaccessible to residents.