Facility Evaluation Report

Licensing Program Analyst (LPA) Dina Alviso conducted a 1 year required inspection and met with Administrator Derrick Whitacre. The inspection is focused on the Infection control procedures and practices of this facility.

Currently eighty-five (85) residents in care, twenty-three (23) of the residents are in memory care unit. Hospice care waiver approved for ten(10) residents. Mitigation plan submitted and reviewed by the Department. Fire clearance approval is for 114 non-ambulatory residents, which includes 6 bedridden. Facility does have an approved dementia plan.

The LPA toured the facility with the Administrator. Facility has sanitizer available in the entry area, and this is where all staff and visitors are screened, and temperatures taken. All screenings are logged. Facility was found to be clean, orderly, and at a comfortable temperature. LPA observed exits free from obstruction. Sufficient supply of hygiene products, cleaners, and paper products for use as needed. Sufficient food supply. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) within the facility for use as needed. Residents have masks available to them for their use if needed and/or wanted. Administrator stated that all staff wear masks in the facility, including when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection, and all the staff the LPA observed during the inspection had a mask on. LPA observed the stairwell(s), and the evacuation chair(s) were in place, including the instructions on their use in an emergency. The LPA observed the fire extinguishers were serviced on November, 21/2021-they are serviced and tagged as required. The local fire Department was out approximately a month ago and checked the fire alarm system-all was approved.