Facility Evaluation Report

Licensing Program Analysts (LPAs) Christi Coppo and Ethel Contreras arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Elizabeth Wise.

At approximately 9:30am LPAs toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Some open food items were found not labeled. Head of cauliflower found with many

black spots and fuzzy brown spots observed. Admin immediately threw away head of cauliflower. Kitchen cabinet containing cleaning supplies was locked.

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 bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 107.4 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 5/23/24. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill 2/5/25. Facility has a backup generator for use during a power outage.

At approximately 10:00am LPAs conducted review of five [5] staff records. Two staff Health Screenings did not have staff name at the top, but did have address listed,so LPAs were able to identify staff to whom the health screenings belonged. Staff (S1) did have Concentra TB documentation present indicating they received a TB test, however, TB results not listed. S1 contacted Concentra in LPAs presence but was not able to get TB results delivered. S1 immediately made appointment to get TB re-done in presence of LPAs. S1 will send proof of TB clearance by no later than 3/19/2025.