Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with back up administrator, Azenette Gregoire. Annual fees are current.

LPA/staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 113.1 and 113.8 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cleaning supplies stored under kitchen sink and in outside laundry room were inaccessible to residents in care. Knives and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last inspected May 2025. Smoke detectors and carbon monoxide detector located throughout the facility were tested and operational. Exit doors have auditory alert system and were functional at time of visit. Medications and medication records were reviewed. Required postings observed.

LPA initiated file review at 9:30 am. Four staff files and four resident files were reviewed. Two out of four staff (S1 &S2) do not have required CPR/1st aid (technical violation issued), but all staff have their 20 hours annual training hours completed. Two out of four residents' (R1 & R2) care plans and medical assessments were not updated within the last 12 months.