Facility Evaluation Report

On 10/16/24 around 12:15 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a Required 1-year inspection. LPA telephoned Sister Mary Ann Leyba, Administrator (ADM) and advised her of the purpose for the visit; ADM arrived shortly after. The facility’s fire clearance was approved for 3 Ambulatory.

LPA and ADM toured the facility including but not limited to bedrooms, bathrooms, kitchen, common areas front yard backyard. All passageways were free of obstruction; no bodies of water were present. There was a comfortable temperature for clients at 71 degrees F. LPA observed adequate lighting and furniture in all rooms for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom measured at 113 F. The shared bathrooms had soap, hand towels and garbage cans. PPE, sanitizer, and paper goods remain sufficient. There was a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. Smoke detectors/carbon monoxide unit were in operating condition during visit. Fire extinguisher was last serviced on 01/05/24. Emergency Disaster drill was last conducted on 09/28/24. Staff, resident and First Aid kit observed complete. Create an emergency contact binder for satellite location.

The following forms are to be updated and submitted to CCLD 10/23/24:

-LIC308 Designation of Administrative Responsibility

-LIC610 Emergency Disaster Plan (Reviewed)

-An updated copy of Administrator Certificate (Upon receipt)

No deficiencies cited. Exit interview conducted. A copy of this report provided to Sister Mary Ann Leyba, ADM