Facility Evaluation Report

On 05/08/2022 at 11:00am, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct an annual visit. LPA Pascua was greeted by staff member, Nicolette Ebanks Taylor and explained the purpose of the visit. LPA asked SM Taylor to call the Facility Designated Administrator (FDA) to inform them that CCL was present. It was learned at this time that FDA was not available at this time and CCL will be meeting with Facility Designated Representative (FDR), Kenroy Anderson. Shortly after LPA met with FDR Anderson. There was one other staff member present, Norris Walsh.

This facility is licensed to served 6 residents, all of whom may be non-ambulatory. This facility has a hospice waiver for 2 and has a dementia plan on file. Current Census was 5.

LPA reviewed 5 resident files. LPA reviewed 3 staff files. All files are current and up to date.

LPA Pascua initiated a tour of the facility with Licensee Placintar.

The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Jorgenson Co and is valid until 02/26/2023..

The kitchen area was toured. LPA observed a non-perishable and perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage.

LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.