In the resident bathrooms Hot water temperatures were measured in both bathrooms. In bathroom #1 hot water measured at 114.8 degrees Fahrenheit, and in bathroom #2 hot water measured at 116.6 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms.

In the hallway, right across from the main bathroom, LPA Haley observed a locked desk with resident medications. In the locked desk/cabinet next to the locked medication desk, there is a locked cabinet with staff and resident files. There was a fully charged fire extinguisher hanging on the wall next to the locked staff and resident files. Down the hallway near the second resident bathroom, a supply of clean linen was observed. Across from bathroom #2, a carbon monoxide detector was observed and right below a fully charged fire extinguisher was mounted on the wall.

In the kitchen LPA Haley observed a perishable and nonperishable food supply in compliance with regulation guidelines. Knives and sharp objects are kept locked in the drawer near the sink.

Continued on LIC809C

In the garage, there was a large back up supply of nonperishable food items. Two additional deep freezers with a supply of perishable food items, and two additional refrigerators with perishable food items. A back up supply of water was observed. In the garage a washer and dryer was observed along with additional cleaning supplies. The remaining items in the garage consisted of additional supplies for the facility, and storage of clothing items.

In the back yard a shaded patio area and a couple chairs was observed. Six storage sheds were observed. The first shed was originally to be used for an isolation room during COVID times. The remaining 5 storage sheds are used for storage of facility supplies, and one is used for storage of tools. No bodies of water observed.

Smoke detectors were observed in all resident rooms, the hallways, living room and in the dining room area. During the inspection smoke detectors were tested and were operational. One carbon monoxide detector was observed in the hallway near bathroom #2.

Emergency evacuation drill will be conducted quarterly per regulation guidelines and the first evacuation drill will be scheduled in March 2024.

Licensee/Administrator Elizabeth Mullins was consulted on the importance of keeping the facility organized. Administrator Mullins has a lot of supplies and was instructed to keep everything organized and to go through everything and dispose of things not needed or being used to prevent clutter.

No deficiencies are being cited as a result of today’s visit.

An exit interview conducted and a copy of this report was provided to Licensee/Administrator Elizabeth Mullins.