Facility Evaluation Report

On 11/8/2021 at 12:30pm Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual inspection. LPA contacted Licensee prior to today's inspection who confirmed no staff or residents have tested positive or shown symptoms within the past 10 days. LPA met with Designated Staff (S1) and was allowed entry into the facility that is licensed to serve a total capacity of 4, today's census is 4. Three of three staff observed on site with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 4/11/2023.

LPA interacted with a random number of residents during this visit and observed residents engaged in activities and crafts. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, garage, restrooms, bedrooms, and common living areas to be clean and in good repair. LPA observed switch cover removed from electrical outlet in restroom and hose uncoiled on back patio walkway. The temperature inside the facility was measured at 69*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 119*F within regulatory range of is not less than 105*F and not more than 120*F. LPA observed the centrally stored medications, toxins and knives to be locked inaccessible to residents. LPA observed medications administered on today's date. The first aid kit was observed in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, tweezers, scissors, thermometers, and Antiseptic solution.