Facility Evaluation Report

At 10:15am on 11/16/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct that annual inspection. LPA met with Direct Care Staff Mary Keefe announced who he is and the reason for the visit. Licensee, David Keefe arrived 30 minutes into the visit.

The Licensee and LPA conducted a cursory tour of the facility. LPA observed at least two days of perishable foods and at least seven days of non perishable foods on hand. LPA observed all four client bedrooms and two client bathrooms located at the south side of the facility. All client rooms have necessary furniture and linin by regulations all lighting fixtures are functioning. LPA tested the water temperature and found it to be within regulation limits of 105*-120*(f). LPA observed and tested smoke detectors which are hardwired throughout the facility and the carbon monoxide was tested and in working condition. The facility has multiple fire extinguisher that are in the green and are regularly serviced by Scott O'brian Fire Safety. LPA noted that there is a living room on the clients side of the facility and and additional living room, staff bedroom, kitchen and dining room on the north side of the facility. LPA noted that all exits were free and clear of obstruction. LPA noted that medications are locked in a cupboard in the kitchen and LPA conducted a cursory review of Centrally Stored Medication Records. LPA noted that there were no citation or violations discovered during the cursory walk through of the facility. LPA conducted staff interviews.

Licensee, direct care giver and LPA conducted a full review of the annual care tools modules. LPA noted that no technical, violations or citations were issued as result of the full review of the annual care tool modules. At this time there are no citations or violations as a result of the full annual facility inspection.

Exit interview, report read, and report provide.