Facility Evaluation Report

On 01/29/2025 at 10:55 a.m. Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Cassie Yang arrived at the facility unannounced to conduct a required one year annual inspection. LPAs met with staff and explained the purpose of the visit. Staff contacted facility Administrator who stated they cannot make it to the facility.

Today's visit LPAs conducted a tour with staff. Areas toured included but not limited to: five (5) bedrooms, two (2) bathrooms, laundry room, kitchen, backyard and common areas. At 11:29 a.m. LPA Ratajczak observed hydrogen peroxide in resident bathroom to be unlocked and accessible to residents in care. Staff stated that they were just using it to clean.

LPAs conducted a file review of facility fire drill record and emergency and disaster binder. LPAs did not observe any drills being conducted for the year of 2024. LPAs informed facility they are to conduct fire drills quarterly.

LPAs conducted a file review of four (4) resident files. Two (2) out of the four (4) resident files were incomplete and missing admission agreements and pre admission appraisals. LPAs conducted a file review of five (5) staff files. LPAs observed that three (3) out of five (5) staff files are incomplete and missing health screening. LPAs observed that four (4) out of (5) staff files are incomplete and missing initial training.

Based on file review LPAs observed two (2) staff working without an active criminal clearance. LPAs were informed S1 has worked at the facility as on call for the total of approximately seven (7) different days. LPAs were informed today was S2s first day in training. Upon LPAs arrival to the facility, LPAs observed S3 returning to the facility. LPAs were informed S3 just returned from lunch break while S1 and S2 was alone with residents in care.