Facility Evaluation Report

Licensing Program Analysts (LPAs) Cuadra and Frank arrived unannounced to conduct an annual required – 1 yr. visit of the facility and met with Licensee/Administrator Kelly Sturgeon. There are residents receiving hospice services and diagnostic of dementia. Annual fees are current.

LPAs/Licensee toured the facility at 9:30 AM, the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices and all auditory devices were working properly. Window screen located at the side of the facility needed to be repaired (technical advisory issued). Fire Extinguisher was found to be last charged on March 2024. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Last disaster drills have been conducted quarterly with the last one being conducted on 11/13/24. Hot water temperature measured 110.8 and 111.4, which is within Title 22 regulation. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Toxins are stored in a locked cabinet in the kitchen. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. However, during facility tour LPAs/Licensee observed one out of six resident's rooms needed a chair (technical advisory issued). LPAs have a discussion with the Licensee regarding the importance to have a chair available in resident's room. Contact information was reviewed. Required postings were observed. The facility does not handle cash resources. Continued on LIC809C...