Facility Evaluation Report

On 10/17/2024, Licensing Program Analyst (LPA) Sarah Benson, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Program Manager, Kristina Black and Senior Social Worker Audrey Woodward-Bowers and explained the purpose of the visit.

LPA Benson, Progam Manager and Senior Social Worker toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, two (2) restrooms and outside area. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured within required Title 22 regulations of 105 degrees F and 120 degrees F. Last disaster drill was conducted and documented on 10-16-24, the facility has been conducting drills every 3 months. LPA observed medication, knives and toxins locked and inaccessible to residents.

LPA observed fire extinguishers, fire detectors, and carbon monoxide detectors.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of three (3) residents' files and four (4) staff files.

Topics discussed: The last centrally stored medication destruction record was recorded 2023. Staff will create an updated medication destruction record and notify LPA by 11-17-24 of completion.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left with Director.