Facility Evaluation Report

On 8/10/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete a case management for a previous visit made on 11/04/21. LPA was COVID pre-screened at time of entry. Administrator was contacted and arrived a short time later. Reason for visit was discussed. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms.

During visit made on 11/04/2022 Licensing Program Analyst M. Garza arrived at the facility and observed two staff (S1 and S2) outside to the right of the facility smoking. Residents were observed to be in the home unsupervised. This poses a potential health and safety or personal rights risk to residents in care. LPA cited Care and Supervision in correlation to complaint #24-AS-20211101082313. A duplicate citation was not given for this today.

On todays visit upon entry, LPA observed the facility front door to be secured with a pin at the bottom of the door. Staff was observed removing the pin and when asked to take a closer look the staff placed the pin in a box. Licensee stated "this was probably old and should not be used anymore". This poses an immediate health and safety or personal rights risk to residents in care. Deficiency cited on the attached LIC809-D

An exit interview was completed. Appeal rights and a copy of this report was given.