Facility Evaluation Report

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue post-licensing inspection. LPA met with administrator Anita Heydon during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks. Additionally, LPA was screened by staff upon entering the facility.

LPA toured the facility and inspection 4 resident rooms, 2 bathrooms, garage area, backyard, kitchen and common living spaces. LPA observed the garage area, and saw it is only used as a storage area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility.

LPA reviewed 2 of 4 resident files and 2 staff record. LPA reviewed medications of 2 resident comparing with Centrally Stored Medication Record and physician orders. Resident files were found to be complete and current. LPA observed the following posted in each resident room: Resident Council Rights, See Something Say Something complaint poster, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

Administrator is pre-pouring medication over 24 hours in advance.

Administrator did not transfer caregiver fingerprints from sister facility to this facility.

Exit interview conducted and appeal rights given.