Facility Evaluation Report

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA conducted the visit with Executive Director, Reginald Jones.

The facility has an approved fire clearance for delayed egress in the East Building on the first and third floor only. LPA, accompanied by Executive Director, toured the interior and exterior of the facility, and inspected multiple rooms. 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 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 resident activities. Hot water temperature at taps accessible to residents were all compliant and measured between 109 and 117 degrees F..

The refrigerator temperature was 40 F and freezer temperature was 0 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas.

There was a swimming pool with a locked gate surrounding the pool. Per the Executive Director, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.