Facility Evaluation Report

01/26/202611:20 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Gail Mason and explained the purpose of the visit.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) client rooms, two (2) bathrooms, common areas, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current.

Activities and outings are planned according to the client’s requests. Medication is locked in a cabinet. Medications were reviewed.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area, bathrooms, and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors and carbon monoxide detectors are all operational. There are no pools/bodies of water on the premises. The facility has been conducting monthly fire drills.

LPA requested the following documents that need to be updated in the facility file: LIC500 Personnel Report, and LIC308 Designation of facility responsibility.

In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was provided to administrator Gail Mason.