Facility Evaluation Report

On 4/28/2023 at 9:05AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Manager, Rachell Paniagua. The facility’s fire clearance was approved for 58 non-ambulatory residents and 10 residents may be under hospice care.

LPA toured the facility with Rachell including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in the med room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full. Evacuation chairs were observed in both stairwell on the third floor. The facility has a written emergency disaster plan

One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food once a week. Freezer’s temperature was registered at -3 degree F while the refrigerator’s temperature was recorded at 40 degrees F. Comfortable temperature was maintained inside the facility. Hot water temperature was measured at 108.6 degrees F in a resident's bathroom and 111.6 degrees F in another resident's bathroom located on different floors of the facility. Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction.

LPA reviewed 5 resident records and 5 staff records starting at 12:10PM. LPA conducted interviews with 3 residents and 3 staff during inspection. LPA also reviewed a sample of resident's medications and MAR (Medication Administration Record).