Facility Evaluation Report

At approximately 12:25 PM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to BEGIN a required 1-year annual inspection and was greeted by Administrator Patricia Harland. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for four (4), clearance for one (1) bedridden resident. Facility currently has two (2) Hospice residents in care, and is approved for all non-ambulatory residents.

At 12:40 PM, LPA observed that facility had removed a door stop at the automatically closing door between living room and bedroom #1 as required by recent fire safety inspection performed to allow care for a bedridden resident.

At approximately 12:45 PM, LPA continued a tour of the facility with administrator and observed the following: Facility is a two story home with residents only living on the ground floor, was a comfortable temperature, and passageways were free from obstructions. Facility is noted to now have evacuation chair at top of the stairs. Water temperatures in Residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, paper products, and incontinent care briefs available to residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Several staff members were observed to struggle to unlock/use the under-the-sink lock where knives and toxins are stored in the kitchen and a technical advisory was issued for the facility to attain an easier/safe locking mechanism. In addition a staff room upstairs was noted to need a lock, in case staff had prescription medicines or valuables and administrator was advised to attain an easy to use door knob lock (such as popular touch pad combo locks) to ensure future safety and security from theft for residents and mobile visitors. Hallway pull-down attic stairs were climbed for LPA to observe additional storage with Christmas decorations and supplies etc.