Facility Evaluation Report

On 02/24/2024, Licensing Program Analyst LPA(s) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility House Manager / Designee Connie Powell (HM). Administrator was contacted via phone and informed LPA to conduct annual with HM.

LPA conducted tour with Staff. The facility was observed to be at a comfortable temperature, clean, in good repair, with no passageway obstructions or fire hazards. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. At 10:20 AM LPA observed milk and other food products past the best by date. LPA also observed tomatoes that were rotten. Fire extinguisher in the Kitchen was last serviced on 01/29/2024 and was fully charged. All common areas were properly furnished and well-lit throughout. First Aid is kept in kitchen cabinet. LPA observed sharps kept in locked kitchen cabinet. The tour continued to laundry area adjacent to kitchen which leads into the garage. Chemicals are kept in locked cabinet in garage. At 11:23 PM LPA observed unlocked laundry detergent in the garage. Smoke Alarm and Carbon Monoxide detector tested and operational. LPA observed medication locked in hallway closet. LPA viewed the staff bedroom downstairs. The exterior tour was conducted. The backyard was observed to have sufficient area for rest and recreational.

LPA toured 3 resident rooms upstairs. LPA observed cleaning supplies accessible to residents. All client bedrooms toured and observed to be adequately furnished. Extra linens observed in the hallway cabinets. Medication was reviewed. Staff records were reviewed for good health and training, all clients’ records reviewed to have Admission Agreement, Physician’s Report and emergency contact information. Last fire drill completed on 01/1/2024. At 1:12 PM During medication audit LPA discovered medication count to have a extra pill that may not have been given to resident in care.