Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Kathryn Gabriel.

According to the facility’s license, the facility has a maximum capacity for fifty-five (55) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of twenty-two (22) residents in care, and all were ambulatory. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present.

LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected all common areas and multiple resident bedrooms. LPA interviewed multiple residents and multiple staff. LPA reviewed care records for multiple residents and personnel records for multiple active staff.

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.