Facility Evaluation Report

On 03/12/25 at 4PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S1) and spoke to administrator on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with ADM and S1. ADM has current administrator certificate# 7000732740 which expired 04/19/25. ADM stated her certification renewal is pending since she has submitted all required documents prior to the expiration date.

At 4:15PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 74 deg F. Hot water temperature was measured at 117 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 2 staff and 5 resident files.

Updated copies of the following documents were collected for facility file:

 LIC308- Designation of Facility Responsibility

 LIC610E- Emergency/Disaster Plan including infection control plans

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided .