Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Christina Gillion.

Upon arrival, LPA observed that staff continue to wear masks and request that visitors do so as well. LPA discussed the recent PIN that allows facilities to discontinue mask wearing but facility has opted to continue to have staff and visitors mask and encourage residents to mask as well. LPA confirmed with Administrator that clients have the right to not wear a mask if they choose. LPA communicated to Administrator that requiring masking for visitors would require an update to the Admission Agreement and residents would need to agree to it. Additionally, facility is required to update their Plan of Operation/Infection Control Plan to outline what their policy is around masking and screening. LPA initiated a tour of the facility around 9:20am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client bathrooms measured at 113, 115, and 116 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Shed containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked.

Fire extinguisher was last inspected May 2022. Facility had a fire inspection on 4/17/2023 and one smoke detector was found to be not working. The vendor that maintains the fire system has a planned service date to repair detector. Carbon Monoxide detectors located throughout the facility were tested and operational.