Facility Evaluation Report

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Tejpal Sekhon arrived later. Facility staff roster information was reviewed.

At approximately 9:30am LPA toured the building and grounds. The facility was found to be 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. Kitchen drawer with sharp knives locked. LPA observed flooring in kitchen to have small cracks/spaces that do not present as a tripping hazard, yet, but LPA discussed with Admin replacing the floor planks so that they do not present as a tripping hazard in the near future. Floor planks in back of facility by rooms #5 and #6 also have small cracks/spaces; per Admin the flooring in the entire facility is scheduled to be replaced/addressed within the year.

While conducting physical plant inspection, LPA observed only one caregiver present at facility. However, LPA observed three residents needing care at the same time. Resident (R1) attempted to get up by themselves to go to the bathroom but started to fall, as they cannot walk properly on their right foot and also having an extremely hard time establishing balance with their walker. Caregiver was down the hall in room #4 assisting resident (R2) with incontinence care. Caregiver had to leave R2 to attend to R1, leaving R2 in their bed. Caregiver assisted R1 on to the toilet, but then had to leave them in order to go back to room #4 and resume attending to R1. While all this was taking place, resident (R3) was in the kitchen requesting help to get out of the recliner chair, as they needed to use the restroom, but caregiver was busy alternating between R1 and R2 such that they could not attend to