Facility Evaluation Report

On 5/21/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Administrator Jacinta Abania and explained the purpose of today's visit. The current census is 11. The facility is licensed for 6 non-ambulatory residents and has a hospice waiver for 8.

LPA Jensen toured the grounds and observed them to be well maintained. All paths were free of obstruction. There is a shaded area and patio furniture available for residents to enjoy outdoor activities. All window screens were in good repair. There are outdoor activities for residents that include gardening and bird watching.

LPA Jensen toured the interior of the facility. At the time of this inspection there was 2 staff members present as well as the Administrator and Licensee. All staff present had criminal background clearance and were associated to the facility. The facility was sanitary and free of odor. All required furniture was present and the furniture and appliances were observed to be in good repair. LPA Jensen observed all required postings displayed in a prominent place. There was adequate lighting throughout including night lights in the hallway. The bathrooms were equipped with grab bars and non-skid mats were available for the shower/bath areas. The bathroom water temperature measured at 117.5 degrees which is within the require range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. The facility thermostat was set at a comfortable temperature for the residents. There is an adequate supply of linens on hand. The first aid kit was determined to be complete. The smoke detector and carbon monoxide detector were observed to be in good working order. There is an indoor sprinkler fire suppression system in place. The emergency disaster plan was reviewed and is current. The fire extinguishers were last serviced in March of 2024 and are compliant. There are generators on site in the event of a power outage. The facility maintains emergency lighting, water and food. LPA Jensen inspected the kitchen and observed a 2 day supply of perishable food and a 7 day supply of non perishable food. All refrigerated food that has been removed from the original packaging was labeled and dated.