The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention.

Infection control practices and Personal Protective Equipment (PPEs) were observed. LPAs observed that the facility has a current Infection Control Plan on file in place.

Physical Plant/Environment Safety:

The facility is a two-story residence which consists of 51 client rooms. 35 client’s rooms are downstairs, and 12 client’s rooms are upstairs. There are 36 bathrooms downstairs and 13 bathrooms upstairs. The showers are jack and jill showers and on each side of the showers there are clients of the same sex. Downstairs consists of a reception/ staff office, activity room, medication room, dining area, kitchen, store, laundry room and 3 patio and 1 parking lot with smoking area. Upstairs consists of pool room, conference room, electrical room, employee break room and Administrator office. Exit doors are free of any obstruction and there are no pools or large bodies of water. All resident rooms were inspected and LPAs observed resident beds and the bedding for each bed were in good condition, adequate lighting provided, storage for resident personal belongings was observed for each resident.

Each resident bedrooms include all required furniture: a bed, chair, lamps, dressers, and sufficient lighting and closet space. LPAs toured 10 client bedrooms: Rm#6, #10, #11, #15, #17, #36A, #37, #41, #43 and #46. Each client’s room has a smoke detector, bed, linen, dresser, light, nightstand, and sufficient closet space. LPAs toured the kitchen and noted working appliances, refrigerator, stove, oven. The facility has fourteen (14) fully charged fire extinguishers located and inspected on 01/29/2025. Sharps were secure and locked in the kitchen drawer and inaccessible to residents. Cleaning supplies were observed in a secured area away in a locked cabinet and inaccessible to clients. Carbon monoxide detector is tested and in working condition. Resident Bathrooms are clean and operational. Toilets and water faucets worked properly. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries that are accessible to residents. Grab bars observed in the bathroom. Bathrooms water temperature was tested between 105 degrees F to 122.2 degrees F in Rm#11 and 123.9 degrees F in Rm#10 which is not within the required 105-120 degrees F regulation. Facility temperature was comfortable and cool. LPAs observed the facility to be clean and appropriately furnished with clear passageways inside and outside.