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25 | 03/13/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 4 clients in care. LPA met with Administrator, Wilson Benoit.
At approximately 9:30am, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner.
All rooms were furnished per regulation. All rooms were in good repair. Extra hygiene products and linens were available. Passageways were free from obstructions. Water temperature in sinks accessible to clients in care were measured at 107.4 and 114.8 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 05/2024. Facilities last disaster drill was conducted 01/05/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were located in the in a locked cabinet and found to be secured. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.
LPA conducted a review of 4 client records. All records had the required documentation. LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. Administrator certificate for Wilson Benoit is pending for renewal as of 01/29/2025.
No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/14/2025:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Emergency Disaster Plan (review, update if needed)
Infection Control Plan (review, update if needed)
Exit interview conducted with Administrator and a copy of this report was provided. |