Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection and met with Rebecca McFadden, Administrator. LPA observed (5) residents resting in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents, (1) of whom may be bedridden. Since the last annual inspection in April 2024, local fire department has approved room #5 for an ambulatory resident. LPA to update the fire clearance information in the system and issue an updated license. Pest Control staff were present at the start of the inspection for the monthly treatment.

LPA and the Administrator toured the interior/exterior of the facility including the common areas, (3) shared resident bedrooms, (2) resident bathrooms, kitchen, laundry. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout. The bathrooms have the necessary grab bars, non-skid flooring, soap, paper towels, and a 20-second hand-washing sign will be posted at each sink. Sharps and toxins are locked in the kitchen and medications are secured nearby in the office. Hot water measured 113*F in a bathroom and inside temperature measured 68*F. Smoke/monoxide alarms are in working order. Quarterly disaster drills are being conducted. There are sufficient linens/towels/blankets and a complete First Aid kit. Required postings are visible in the common area, including the Emergency Disaster Plan, and Resident Personal Rights. There are open exits in the backyard. Currently there is a patio project going on to add seating and flowers. Residents participate in art work, pet therapy. LPA reviewed (2) resident files and (3) staff files. Files were organized, current and complete. Medications were reviewed for (1) resident, orders match medications being administered, and documentation is current. Staff is cleared and associated and completing the required initial/continuing annual training. Administrator RCFE #7020839740- exp 11/15/25. Discussed updated regulations. LPA requested an updated copy of liability insurance, LIC308 and LIC500 be submitted by 4/15/25. There were no deficiencies observed and no citations being issued. Exit interview. Copy of report provided.