Facility Evaluation Report

Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived at the facility unannounced on 4/19/2023 to conduct a Required -1 Year Inspection utilizing the infection control domain. LPA met with Administrator, David Stir, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

The administration certificate expires 3/27/23, however, the new certificate has not arrived.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. Bathrooms and bedrooms were clean and in good repair. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. Smoke alarms were checked and in good working order. Fire drills are conducted as required. LPA observed an adequate amount of linens and found the first aid kit to be complete .Hot water temperature was taken and measured at 120. degrees.

LPA reviewed 5 resident records and staff records. Resident files were found to be complete and current. A review of staff records indicates that all facility staff have received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates. Facility is conducted staff training as required.

In the areas toured no immediate health, safety, or personal rights violations were observed.