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25 | Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/1/23 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator stated that they would be available by phone if needed arrived to assist.
LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 6 resident bedrooms, 3 bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA advised that a new facility sketch be submitted to reflect that Rm 4 is a resident room and Rm 5 is a staff room.
LPA reviewed 6 resident files. An advisory was issued to insure LIC 602s are accurate for resident conditions and that LIC625s are done annually, including reflecting resident participation.
LPA reviewed 2 staff files. LPA advised that documentation of training contains dates of when training occurred.
No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility. |