Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Elizabeth Matos. Facility contact information was reviewed.

At approximately 10:00am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. LPA and Admin discussed labeling opened food items with date of opening or date of expiration. Kitchen has a half door that locks and separates the dining area from the kitchen making the entire kitchen area inaccessible to residents.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required grab bars. Admin will add non-skid strips or non-skid mat to each shower. Water temperature in sink accessible to residents in care measured at 106.5 degrees F in the kitchen, 113.4 degrees F in Room#2, and 106.1 degrees F in the main bathroom which are all within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 8/25/2023. LPA and Admin discussed having the fire extinguishers serviced immediately. Smoke/Carbon Monoxide detector located throughout the facility were tested and operational. Facility does conduct fire drills but has not documented the dates of the drills. LPA and Admin discussed drills must be conducted quarterly and must be documented going forward.

LPA discussed training materials for staff training. Currently Admin is using her facility policies and regulations for training. LPA and Admin discussed using an approved vendor for staff training and purchasing a yearly subscription with an approved vendor.