Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Direct Support Professional, Nathaniel Neish. Acting Administrator, Jasmine Sampson and Licensee, Jenero Jefferson were available by phone.

Upon arrival, LPA observed that staff was wearing a mask and screened LPA. LPA communicated to staff that masking and screening was no longer required per current guidance and asked if facility was choosing to continue those practices as a policy. Staff was unsure. LPA has previously sent communication to Licensee requesting an updated Infection Control Plan which should include facility policy on masking and screening. LPA initiated a tour of the facility around 8:40am 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 bathroom measured at 108 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinet 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 March 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent fire/disaster drill was conducted March, 2023.

Four staff files and four resident files were reviewed. Three of four staff do not have required First Aid and CPR certificates. Four out of four staff do not have required documented training. Three of four staff plus the identified Administrator are not associated to the facility.