Facility Evaluation Report

On 9/25/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Sister Faustine. The facility currently provides care for 6 residents.

LPA continued with a tour of the facility with Sister Faustine, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be charged. Smoke and carbon monoxide detectors observed in the hallways were interconnected and in functioning order with a recently completed fire safety inspection in February 2024.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. Cleaning supplies and other toxins are safely stored in locked cabinets in laundry room, all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items with plenty of additional linen supplies. Residents that were awake during the inspection were observed interacting with staff/volunteers in their bedrooms, in addition to the facility encouraging regular family visits. In addition, there is a large outdoor patio with appropriate shade and activity/exercise equipment for resident use. Upon a sample review of staff and resident files, LPA found all items to be in order and updated. Lastly, LPA conducted a spot check of medications and found all medications and records to be accurately documented.

LPA requested the following documents be sent to CCL by COB 10/9/2024:

LIC 308 Designated Facility Responsibility