Facility Evaluation Report

On 3/6/20245 Licensing Program Analyst (LPA) K.Kaur arrived unannounced for an annual inspection visit. LPA was met by Christina Gomez (Assistant Executive Director). LPA introduced self, explained reason for visit and was permitted entry into the facility. Administrator, Maria Ceballos arrived a short time later.

LPA toured the facility with the Assistant Executive Director. All pathways, entrances and exits were clear from obstruction. LPA did not observe Complaint Poster (PUB 475) posted in the main entryway. LPA toured locked housekeeping room, and laundry room. LPA observed facility common areas were furnished with sufficient seating. The tour continued to the facility dining room and facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed a 7-day supply of non-perishable foods and 2-day supply of perishable foods.

Residents observed in common areas and in rooms. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. Hot water temperature was tested between 105 degrees F and 120 degrees in restrooms. Carbon monoxide detector tested and operational. LPA observed delayed egress doors. Facility observed with a signal system. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. Cleaning supplies and chemicals are kept locked maintenance room. At 11:04 AM LPA observed Fire extinguishers with expired service date of 10/17/2023. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. Staff files had health screenings/ TB Clearance. It was verified that current staff on duty are CPR certified. At 1:48 PM LPA observed no documentation of annual continuation training. LPA conducted a medication audit. Two medications for Resident R1 were short one pill each that were accidentally opened, which were destroyed but not logged in the destruction record.