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25 | On July 7, 2023, Licensing Program Analyst (LPA), Jacqueline Shaw Ross conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA met with Administrator, Audra Bristol and explained the nature of the visit and was granted entry into the facility. The facility was inspected inside and out. At the time of the visit, seven (7) staff and thirty-two (32) clients were noted to be listed. LPA Shaw Ross conducted staff and client interviews.
The facility is made up of four (4) wings; North, South, West and main building, and has thirty-seven (37) residential rooms. Each residential room has their own private bathroom and shower. The facility appears clean and free of odors. LPA observed that the facility did not have any health and safety issues. Staff present have criminal record clearances and are appropriately associated to the facility. Client rooms are clean and appropriately furnished. Food supplies are sufficient. LPA observed all toxic chemicals and other hazards secured and inaccessible to clients. Medications are centrally stored in a locked cabinet. Furniture throughout in the facility appears to be in good repair. Outdoor space is free of hazards. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are fully charged. Water temperature was tested at 106.2 degrees Fahrenheit.
LPA inspected the staff and client records. Staff files had the required documentation including First Aid Certifications and training documents. LPA inspected medications and medications appear to be dispensed appropriately according to physician's orders. The facility is completing emergency drills on a regular basis.
During the inspection, no deficiencies were observed. An exit interview was conducted and a copy of the report and LIC 811 was provided.
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