Routine inspection·July 12, 2024

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Director of Patient Services Sarah McKenzie who was informed of the purpose of today's visit. At the time of the visit there was three (3) staff and six (6) residents present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. LPA observed outdoor furniture and shaded area for clients. Detergents, cleaning solutions, and sharp and dangerous objects were observed to be locked and inaccessible in a closet located near the dinning room area. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 109.8 degrees F which met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed two (2) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Resident files were reviewed and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate. Resident medication was centrally stored and locked in a medication cabinet located near the kitchen area. LPA reviewed medications prescribed to the residents and found all medication with required labeling found to be in place. LPA reviewed the facility's emergency and disaster plan and infection control plan. All facility exits were clear from obstructions. LPA observed emergency supplies, charged fire extinguishers, and first aid kit with all required items. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Director McKenzie.