Facility Evaluation Report

On 05/03/2023 at 12:30 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Required Annual Inspection. Upon entry, LPA disclosed the purpose of the visit with staff. At approximately 1:00 PM, Administrator (ADM) Annette Sanchez arrived.

LPA and ADM inspected the facility inside and outside. LPA reviewed staff and client files and interviewed staff and clients. During the inspection, 1 A-Type and 4 B-Type citations were issued for the following deficiencies (refer to LIC809-D for details):

Physical Plant/Environmental Safety - Type A: 87303(e)(2) - hot water 138.8 degrees F

Personnel Records/Staff Training - Type B: 87411(c)(6) - staff training documentation not being maintained in personnel records at the facility

Disaster Preparedness - Type B: 1569.695(a)(2) - inadequate supply of emergency food and water

Residents with Special Health Needs - Type B: 87608(a)(3) - no written physician's order for bed rail for half of the length of the bed in 2 of 2 residents' files

Residents with Special Health Needs - Type B: 87705(h) - side and back gates not self-closing

Exit interview conducted and a copy of this report provided via email.