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25 | Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Carrie Fairchild. Facility contact information was reviewed.
At approximately 9:30am LPA and Admin initiated a tour of the buildings and grounds and made the following observations: Facility consists of four suites with one suite being used for administrative purposes and three designated for participants. Facility was clean and at a comfortable temperature. Passageways were free from obstructions.
Water temperature in bathrooms used by participants measured at 118.5 degrees F in the kitchen, 109.2 degrees F in bathroom on side one, 111.2 in bathroom on side two, and 109.1 degrees F in bathroom on side three which are within the range of 105 to 120 degrees F allowed per regulation. Cabinets containing cleaning supplies were locked. Clients bring their own lunch and those who stay at the facility during the day eat in common areas. Refrigerators for client lunches were clean and in good repair.
Fire extinguishers were last inspected 11/19/24. Facility has a centralized smoke alarm system that is maintained by a vendor, most recent service was conducted 8/9/24. Most recent fire/disaster drill was conducted 11/19/24. The most recent inspection of facility vehicles was conducted by a vendor on 11/26/24. Admin provided LPA with documentation from all vendors.
At approximately 10:30am LPA conducted a review of 5 participant records. All required documentation present. At approximately 11:15am LPA conducted review of 5 staff records. All required documentation present.
Facility currently stores and assists clients with self administration of PRN medication. Per Admin, the facility does maintain a PRN log. LPA verified PRN log. The medication follows the client with staff in a lock box. The lock box is signed out and in twice per day and a medication count is performed after each sign in.
No deficiencies cited during this inspection. |