Facility Evaluation Report

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA was granted entry by Staff Sagrario Anguiano Mendoza. Staff contacted the Administrator who responded to the facility to assist with the visit. LPA met with Administrator Angel Zazueta. Licensee Miriam Arias arrived later during the inspection.

When LPA arrived at the facility LPA observed medications on the dining room table, the kitchen counter, and the medication cart unlocked and open with medications on top of the medication cart. During the visit, staff did not lock the medications. LPA observed bleach on the kitchen counter and Lysol on top of the medication cart. A tour of the facility was conducted. During the tour, the medication closet was unlocked with additional medications inside. Medication closet remained unlocked during the visit. Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Resident bathroom water temperature measured at 135.4 F. Laundry room had chemicals unlocked. Laundry room led to the garage with tools and other toxic substances. LPA took photos. Smoke detectors and carbon monoxide are operating properly. Fire extinguisher last serviced 3/6/24. Facility does not have a record of conducting emergency drills. Complete Plan of operation was not available to be reviewed.

A tour of the outside was conducted. LPA observed round up pesticides on the outside table next to a propane tank. There was outdoor seating for the residents.

Resident and staff records were reviewed. Administrator certificate is current. S1 did not have current CPR/First Aid and was the only staff at the facility when LPA arrived. Facility did not have a file for S1 for licensing to review. S1 was not associated to the facility. S1 was not listed on the personnel report in LIS or in Guardian. S1 was removed from the facility. Facility does not have a staff schedule.