Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the CARE tool. LPA met with staff and explained the purpose of the visit. Administrator informed LPA on the phone she was an hour away and unable to make it.

LPA observed three residents in care with one resident on hospice services. LPA was informed two residents are at the hospital for evaluation. Facility census is compliance to license.

Today's visit, LPA and staff conducted a tour of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: four residents bedrooms, laundry room, staff room, kitchen and the common areas. LPA observed the common area to have the mandated compliance posters posted. LPA observed fire extinguisher to be recently serviced on November 5, 2024. Facility temperature was observed at a comfortable 72*F. LPA observed facility to have ample perishable and nonperishable food supply. LPA observed carbon monoxide detectors to be working and in good condition. Sharps are stored in staff room which was observed to be locked. LPA observed laundry room to be locked. Medications are stored in closet, locked and secured.

Emergency Disaster Plan was observed to be reviewed and updated in 2024, pending review for 2025. File review conducted for five out of five residents in care. LPA observed R1 and R2's medical assessment present with no documentation of tuberculosis testing.

As a result of today's visit, deficiencies cited.

Exit interview and a copy of report and appeal rights was emailed.