Facility Evaluation Report

On 01/16/2025, Licensing Program Analyst (LPA) Jilll Nakagawa arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Mary Grace Defeo, resident care director and explained the purpose of the visit. Licensee was contacted by phone and arrived shortly.

LPA Nakagawa and Ms. Defeo toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free. Each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. LPA observed each bedroom to have the necessary furnishings with working lights and windows with screens.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured within the required range. LPA observed several fire extinguishers, fire detectors, and carbon monoxide detectors throughout out the facility. LPA observed the first aid kit to be complete and ready for use.

LPA reviewed a total of 5 residents' files; 3 of 5 were missing the Inventory list and 1 resident's information informing of possible prohibited condition; and five (5) staff files which were reviewed. 5 of 5 were missing training documentation.

LPA requested resident R1 to be sent out for immediate assessment.