Facility Evaluation Report

On 10/03/2024 at 1:30PM, Licensing Program Analysts (LPAs) Renese Howell-Small and Melody Brown conducted an unannounced visit at this location to commence a health and safety check. LPAs Howell-Small and Brown identified themselves and discussed the purpose of the visit with House Manager, Douglas Hicks due to complaint # 56-AS-20240925153435.

Fourteen (14) residents in care were present during visit. LPAs observed imminent health and/or safety concerns observed at the time of visit as LPAs conducted a medication audit for three (3) residents and noted that multiple medications were not given per their doctor’s order. Deficiency will be issued. LPAs observed health and/or safety hazards at this location as no sufficient staff coverage were observed to provide appropriate care and supervision to residents in care. During the visit, LPAs observed that only one (1) staff working from 6:00 AM to 2:00 PM and there are fourteen (14) residents of which three (3) residents are on hospice and three (3) residents have dementia. Deficiency will be issued. Furthermore, LPAs observed no emergency supplies available. Deficiency will be issued. Also, LPAs inspected the outside perimeter at this location and observed no health and/or safety hazards. LPAs inspected the food supplies at this location and observed an adequate supply of perishable and non-perishable food. The needs of the residents in care appear not being met during this inspection.

An exit interview was conducted where this report, LIC809, LIC809D and Appeal Rights were discussed and provided to House Manager, Douglas Hicks.