Facility Evaluation Report

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Business Office Manager Emerald Jordan and Executive Director Mercedes Margritz. The facility's license shows a maximum capacity of fifty-six (56) non-ambulatory residents. Additionally the facility is approved for a secured perimeter and holds a hospice waiver for twenty (20). There is a separately licensed Adult Day Program on the same property. During today’s inspection there were forty (40) residents in care.

LPA and Executive Director Margritz toured the interior and exterior of the facility and inspected a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms visited contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: one common bathroom sink was measured at 106.8F. 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. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. As the kitchen is locked and requires code access, knives were inaccessible to residents. Kitchenettes accessible to residents throughout the facility did not contain knives or similar sharp objects.