Facility Evaluation Report

Licensing Program Analyst (LPA) Jose De La Cruz made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Director of Resident Services (DRS) Corina Norton. The facility's license shows a maximum capacity of five hundred and sixty (560) residents age 60 and above. One hundred and nineteen (119) might be non-ambulatory residents and five (5) might be bedridden. During today’s inspection there were two hundred and eighty-four (284) residents in care, four bedridden and twenty-one non ambulatory.

LPA arrived at 8:20 am, facility looks clean and in good repair and decorated for the Holidays. At 8:35 am LPA requested residents and staff files, at 9:16 am LPA reviewed residents’ files and at 10:21 am LPA reviewed staff files.

At 12:10 pm, LPA and DRS toured the facility, toured the interior and exterior and inspected four residents’ rooms, two cottages, two of the four clinics and two activity rooms as well as a physical inspection of four of the seven floors. During the inspection, LPA measured the water temperature and found that the main building had approved readings of 115 degrees Fahrenheit, but a cottage and one of the dementia care facilities had readings of 128.1 and 126.3 Fahrenheit degrees.

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linen and hygiene supplies were present at the laundry room, as well as Personal Protective Equipment.