Facility Evaluation Report

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a required 1 year visit. LPA was greeted and granted entry by DSP Romina Mas, where LPA explained the purpose of the visit. Romina has obtained criminal record clearance and is associated to the facility. The Administrator was unavailable to come to the facility for LPAs visit. At the time of the visit there was one (1) staff and one (1) resident present , as they had an on site doctors appointment scheduled during LPAs visit.

LPA conducted a tour of the interior and exterior of the facility. The facility was observed to be clean, clutter and odor free. The bathrooms were equipped with grab bars and toilets were observed to be in working order. However there was a brown metal chair observed in the shower, that was confirmed to be used by residents. The chair was removed at the time of LPAs visit. Facility is to follow up in regards to obtaining a proper shower chair. The P&I was counted for all four residents and all monies were presented and accounted for. LPA discussed the need for the resident appraisals/needs and services plans to be reviewed and updated accordingly.

The smoke and carbon monoxide detectors were tested and found to be operable. The emergency disaster drills are being conducted every six (6) months, the last fire drill was conducted on 9/23/23. The hazardous chemicals, medications and sharps were observed to be locked and inaccessible to residents in care. There are two bathrooms designated for residents use. The water temperature was checked and measured at 116.9-117.1 degrees, which is within regulatory limits. There were no bodies of water, firearms and/or ammunition on the premises. In the backyard there is a shed that is used for storage. LPA will send a copy of the PUB475 to the facility via email as it was not observed at the facility.

LPA observed for there to be old work out equipment in the backyard that is rusted. The back resident bedroom resident #1 (R1) room, was observed to have chips, tiny holes and fragments off of their wall