Facility Evaluation Report

On 03/12/2024, Licensing Program Analyst (LPA) Brian Phillips arrived unannounced for an unscheduled visit to conduct a required Annual site inspection visit at the facility above. When the LPA arrived, they were greeted by Administrator Dorothy Berger, Licensee Margie Halsell, and Business Manager Susie Halsell and informed them of the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of Fourteen (14) residents. The facility is approved for Thirteen (13) non-ambulatory residents, of which Three (3) may be bedridden, with an age range of residents sixty (60) years of age and older. The facility has an approved Hospice Waiver for Seven (7) residents. The physical plant of the facility consists of two connected buildings with resident bedrooms, restrooms, shower areas, a beauty salon, Staff offices, laundry room area, storage room areas, and Staff office rooms/areas. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio area with furniture and shade. The exterior of the facility has an approved secured perimeter which consists of a metal fence around the entire facility with locked gates. The gates are locked through a combination of electronic punch numbered locks as well as traditional key locks.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). Additional perishable food items were maintained in a storage area in the garage of the facility as well as an extra refrigerator and extra freezer located in the garage of the facility. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. Items that could constitute a danger to residents are kept inaccessible to residents in the kitchen area. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. Continued on 809-C