Facility Evaluation Report

Licensing Program Analysts (LPAs) Cuadra and Stevenson arrived unannounced to conduct an Annual Required inspection and met with Administrator, Debbie McCulloch. Annual fees are current.

LPAs/staff initiated a tour of the facility around 11:30am and made the following observations: Facility was a comfortable temperature, Cleaning supplies are stored in a closet that was locked at time of inspection. Required postings were observed. LPAs/staff observed ramp blocked with caution tape and not being used due to moss/slippery (technical advisory issued). Client rooms were furnished per regulation. Extra hygiene products and linens were available. Medications were reviewed, centrally stored and locked in the office. Fire extinguisher was last inspected May 2024. Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent disaster drills were conducted 11/27/24. Water temperature in client bathrooms measured at 104 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. LPAs/staff observed bathroom #2 & 3 did not have tight-fitting covers on their containers (technical advisory was issued). 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. LPAs/staff noticed expired food located in the locked shed area. Per Administrator, the expired food is waiting to be discarded and show LPAs another food pantry area located in the garage where they keep their food stored per regulation. Also, LPAs/staff observed the refrigerator located in the kitchen had a lock and it was observed unlocked during the visit. Upon LPAs inquiring with staff, LPAs were informed that they do lock the refrigerator at night. LPAs had a conversation with Administrator and staff that snacks need to be made available for clients in care. LPAs observed fruits available in client's dining table.