Facility Evaluation Report

Licensing Program Analysts (LPAs) Liliana Silveira and Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 01/16/2024. The facility file was reviewed prior to the visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Michael Sokolowski.

According to the facility’s license, the facility has a maximum capacity of 105 residents, all which will be non-ambulatory and seven may be bedridden (and the bedridden residents may only reside on the ground floor). During today’s inspection, according to records, there were a total of 71 residents in care, of which 43 were non-ambulatory and none were bedridden.

During today’s visit, LPAs, accompanied by licensee’s staff, toured the interior and exterior of the facility and inspected common areas and a sampling of resident bedrooms. LPAs privately interviewed multiple staff and residents. LPAs also reviewed multiple staff and resident records/files. The files which were reviewed contained the required documents.

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained required furniture. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Confidential records and centrally stored medications were kept in locked areas.

The facility had at least two days of perishable food and seven days of non-perishable food present. The facility had cooking and dining utensils to facilitate resident meal service. The Walk-In Refrigerator’s temperature was compliant at 40 F, and the Walk-In Freezer’s temperature was complaint at 0 F. The facility’s ambient internal temperature was compliant at 74 F. [CONTINUED ON LIC 809-C]