Pre-licensing visit·April 19, 2021

At 10:00 AM Licensing Program Analyst (LPA) Mike Barrett contacted the facility via FaceTime application, using iPhone technology, to commence a pre-licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the announced video call and spoke with Administrator (AD) Brian Schott. The facility contains 6 bedrooms with 4 full bathrooms, is a single-story building with an attached 2-car garage. This pre-licensing inspection was due to a change in ownership and the facility had four (4) residents in care at the time of this visit. The inspection was as follows: Physical Plant: At 10:10 AM LPA conducted the virtual inspection and toured the inside and outside of this facility with AD Schott, including but not limited to the kitchen, common areas, laundry room, garage, bathrooms, bedrooms, back patio and walkways. LPA observed that the facility was clean, there were no obstructions to the interior or exterior walkways and the backyard gates were observed to be self-closing and self-latching with alarms installed. The kitchen was clean, and knives were stored in a locked cabinet. There were smoke detectors installed throughout common areas as well as all of the bedrooms which are centrally wired and observed to be in good operation. LPA observed that there were alarms installed on all of the exit doors that were observed to be functional. Fire extinguishers were located in the kitchen and was observed to be appropriately charged and mounted. Centrally Stored medications were observed to be stored in a locked cabinet in dining room area where the complete first aid kit was located as well. Bedrooms: Bedrooms were observed to have made beds, bedroom furniture, appropriate lighting and exit doors were free of obstructions and equipped with functional alarms. Continued on page 2. Continued from page 1. Bathrooms: Bathrooms were equipped with grab bars and non-skid mats in the shower stalls and the water temperatures from the faucets measured within 114.5, 111.4, 115.1 and 116.0 degrees F. Faucets were in good operation, hand washing signs were posted and the facility also equipped the toilets with handled, raised commodes. Supplies: There was a sufficient supply of paper products, cleaning supplies, hygiene products and linens. Food Service: The facility met the 2-day perishable and 7-day nonperishable on hand food supply as LPA observed fresh fruit, canned goods, bread, dairy products, eggs, frozen meats and cereals in both the kitchen and garage. The facility had two (2) refrigerators, a freezer and food stored in the kitchen and in the garage. The food was observed to be stored appropriately and away from cleaning supplies. Records: Staff and Resident files were kept at the facility and available for review. LPA reviewed one (1) resident file and one (1) staff file and observed them to be in good order. Administration: LPA observed and reviewed the facility’s Emergency Disaster Plan, Resident Personal Rights and “Let-Us-No” poster posted in the facility. Component III Orientation was waived due to the facility is being re-licensed and the Administrator has been serving in this capacity for several years over this facility. Administrator stated that the facility does advertise for dementia care. An exit interview was conducted with the Administrator and a copy of this report was provided via email for signatures.