Britannia Lodge

Type of visit: Required - 1 Year

On 4/28/2026 at 1:20 PM Licensing Program Analyst (LPA) Toni Nwala conducted an unannounced annual required visit. Upon entry, LPA was greeted by Patricia Hounsell, Administrator, and informed them of the purpose of the visit. At the time of the visit, there were (3) staff members and six (6) residents present. Facility Overview: The facility is a one-story home with (6) bedrooms and (3) bathrooms, including an attached garage. There is a fenced swimming pool in compliance with building code. There are no known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 111°F. There were 3 fire extinguishers, and all had current inspection tags dated 11/4/2025. Continued on LIC809-C.... Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for (3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. (6) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for (6) residents, confirming that all medications were listed and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 10/1/2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during and a copy this report was reviewed and provided.the state’s words, verbatim · CDSS document, Apr 28, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Patricia Hounsell, Administrator, and informed them of the purpose of the visit. At the time of the visit, there were (3) staff members and (5) residents present. Facility Overview: The facility is a one-story home with (6) bedrooms and (3) bathrooms, including an attached garage. There is a fenced swimming pool in compliance with building code. There are no known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 112°F. There were 3 fire extinguishers, and all had current inspection tags. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C..... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for (3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. (5) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for (5) residents, confirming that all medications were listed and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 1-3-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, Apr 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Patricia Hounsell and informed her of the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include soap at hand washing stations (residents use cloth hand towels which are single-use), and tight-fitting lids on trash cans. Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 111.3 degrees. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed a knife block in the kitchen which contained numerous knives which could be a danger to residents. Deficiency cited. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. The facility has an in-ground pool which LPA Colvin observed to be gated and locked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. LPA Colvin observed that though the facility has residents with Dementia, they do not have auditory alarms on the exit doors. Deficiency cited. Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents. Facility has a hospice waiver for 2 residents. Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs. Resident Records: LPA Colvin reviewed the files for all 6 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that Resident 1 (R1) is diagnosed with Dementia, and therefore needs to have a Physician’s Report completed annually, but R1's last Physician's report is from 2022. Deficiency cited. Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the kitchen as well as in the office and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. Planned Activities: LPA Colvin confirmed with interviews of staff and residents that the facility provides activities for residents to engage in and are tailored to their interests. Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file. LPA Colvin inquired about quarterly emergency disaster drills, and staff stated that they conduct the drills, but they do not document them. LPA Colvin will be issuing a Technical Violation instead of a deficiency. LPA Colvin advised facility staff to start documenting the drills. An exit interview was conducted with Administrator/Licensee Patricia Hounsell and a copy of this report, LIC809D, LIC9102 TV, LIC9098 Proof of Corrections, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 15, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.