1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 | Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself, and disclosed the purpose of the visit to Administrator Richard Willey. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one may be bedridden in bedroom #4. Bedroom #1 was approved for ambulatory only. The facility was also approved for a Hospice waiver for two. At the time of the inspection, the facility had a census of five non ambulatory residents. Facility is the process of increasing their Hospice Waiver, and submitting facility sketches and application to change bedroom #1 to non-ambulatory.
The LPA, accompanied by Licensee, toured the interior and exterior of the facility, and inspected each room. The facility
was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms
contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.
There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored.
Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients.
Medications were labeled, and stored in locked areas.
No pools or bodies of water on the premises. Per staff, no firearms or ammunition were kept at the facility. Carbon
monoxide detectors, and facility telephone were all working. Fire extinguisher was present. First aid kit was readily accessible. Required licensing postings were observed in visible areas of the facility.
LPA interviewed staff and reviewed multiple staff and client records/files. The files which LPA reviewed contained
required documents. No deficiencies were observed or cited during today's annual inspection.
An exit interview was conducted with licensee Richard and Elizabeth Willey, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided. |