Facility Evaluation Report

On April 29, 2024, Licensing Program Analyst (LPA), Jacqueline Shaw Ross arrived to the facility unannounced in order to conduct the required annual inspection. LPA Shaw Ross met with Administrator, introduced self, and stated the purpose of the visit. A tour of the facility was conducted both inside and outside. The facility is a single story building with four bathrooms.

Physical Plant: The physical plant, is in good condition, neat, and orderly. Outdoor and indoor passageways are free of obstruction at the time of this visit. The day program activity rooms have the required furniture; such as tables, chairs, storage space, and sufficient lighting. The building temperatures throughout was comfortable. All activity rooms were equipped with the required items. Hot water temperature was measured in several of the restrooms, and tested at 118 degrees which is within regulations. The restrooms were equipped with liquid soap and paper towels were available. LPA Shaw Ross toured the kitchen and observed the kitchen area to be clean and functional. The facility had activity schedules posted and available for review. The day program has emergency food and water. LPA Shaw Ross inspected the common areas. Smoke detectors are hard wired and were tested. There were multiple fire extinguishers throughout the building. Carbon monoxide alarms, along with smoke detectors were observed. There was a locked and centralized storage area for medications. Medications are contained in bubble packs and are dispensed accordingly. The day program had a designated area for resident and staff files, and it was lockable. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There was adequate seating in the common areas and sufficient space for activities. LPA Shaw Ross observed monthly activity calendars. LPA Shaw Ross reviewed five staff files, five resident files, and conducted three staff interviews and three resident interviews. There were no regulation violations observed during todays visit.

An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to Administrator.