Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a post-licensing inspection and initially met with Dajah Thomas, caregiver, who contacted the Administrator by phone. LPA stated the reason for today's inspection. Myles Baxter, Member arrived to assist LPA with the inspection around 1:30 pm. LPA observed (1) resident begin to eat lunch at the start of the inspection and a second resident in her room. The facility is approved for (6) non-ambulatory residents and has an approved hospice waiver for (6) residents. The Administrator arrived at 1:45 pm. Staff shift change took place at 2:00 pm and staff, Jillian Kulinski arrived.

LPA toured the interior/exterior of the facility including the common areas, (2) private resident bedrooms, (2) shared resident bedrooms, (2) resident bathrooms, kitchen, laundry and garage. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout and both bathrooms have the necessary grab bars, non-skid flooring, paper products and soap. There is sufficient 2+day perishable and 7+ day non-perishable food on site. There is a small refrigerator for refrigerated medications in the kitchen and both refrigerator temperatures are monitored regularly. Sharps are locked in the kitchen.

LPA reviewed 2 resident files and 2 staff files. Files were organized and contain the required paperwork. Staff is cleared/associated and has completed the required initial training. Training certificates observed on file. Staff have First Aid/CPR certifications also. Medications are centrally stored and secured near the kitchen. LPA reviewed the Dementia Plan of Operations that includes the updated regulations. Discussed updated changes to be made to the Admission Agreement effective Jan 2025. LPA obtained a current copy of liability insurance.

There are no deficiencies cited in this report. Exit interview. Copy of report provided.