Facility Evaluation Report

Licensing Program Analysts (LPAs) Amy Rodgers and Eryn Kane conducted a continuation of an unannounced Required Annual Inspection. LPAs conducted the visit with Executive Director, Chris Neale.

The facility has an approved fire clearance for delayed egress in the East Building on the first and fourth floor only. LPAs, 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. Doors, windows and screens, toilets, and showers were in working order. 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. 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. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Required licensing postings were observed in visible areas of the facility.

LPAs interviewed multiple staff and residents. The interviews did not raise any significant licensing concerns. LPAs reviewed multiple staff and resident records. The reviewed files contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Executive Director, Chris Neale to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.