Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1- year annual inspection. LPA met with Executive Director (ED) Jolie Higgins.

LPA entered the kitchen with the ED. Refrigerator temperature maintained at 32 degrees F and freezer temperature maintained at 1 degree F. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. Items inside the refrigerator observed covered and labeled. Fire extinguisher last serviced on 05/30/2023. Facility has sufficient amount of silverware and dishes.

LPA toured Compass Rose (aka Memory Care) with ED to include 6 resident apartments (RM 137B, 133, 130, 128, 124, and 123), bathrooms, activity room, dining room and exterior. Temperature in memory care maintained at 74 degrees Fahrenheit. Hot water temperature in RM 133 maintained at 110 degrees Fahrenheit. Oxygen in use signs posted in appropriate areas. All chemical, disinfectants, and hygiene items observed secured. Residents observed participating in activities during visit. 1 out of 2 egress doors in the patio observed in disrepair as the egress door does not open or alarm. The facility has another fire exit egress door in the patio area in case of emergency. 1 egress door inside memory care observed in disrepair and does not alarm. Facility initially had a latch lock on the door installed at the very top of the door that is not within arms length. LPA advised to remove the latch lock on the door in case of emergency. Facility staff immediately removed the lock and taped multiple caution tape signs on the door. Facility placed the lock temporarily to avoid resident elopements while they wait for the door to be repaired. The facility scheduled technicians to repair the egress doors this week. SEE LIC809-C.