Facility Evaluation Report

Licensing Program Analyst (LPA) Adrian Mangina conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Kim Keane Director of Program Development with whom LPA discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of seventy-eight (78) clients. During today’s inspection, there were a total of seventy-seven (77) clients in care. Facility is licensed for 20 bedridden and 20 non-ambulatory residents. There are eight (8) separate homes. This facility does not feature a secured perimeter or delayed egress doors in the main campus. Memory Care houses has delayed egress available but it is not utilized for residents at this time.

LPA, accompanied by Kim Keane, toured the interior and exterior of the facility, and inspected the homes. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. LPA inspected a sampling of bedrooms, and all contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Common spaces were toured. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperatures were compliant ranging from 68.4 to 72.5. Hot water temperature at taps accessible to clients were all compliant: ranging from 108.7F to 109.5F. Kitchen sinks were complaint, with temperatures averaging 115.4F.

The average Refrigerator temperatures were 40F and freezer temperatures were 0F. There were at least 2 days of perishable food, and at least 7 days non-perishable food present in all the facilities and all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic