Facility Evaluation Report

On 1/29/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Adrianna Garza. LPA was granted entry. Administrator (A1) Gonzalo Cruz arrived shortly after LPA’s arrival. 2 residents were present during visit. The other 2 attended day program. 1 of the 2 that attended day program arrived to facility during visit.

LPA toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. LPA advised be repaired or replaced. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 31 degrees F. Thermometer was installed to check temperature. LPA advised to have a thermometer for both the freezer and refrigerator in at all times. Fire extinguisher was observed with a purchase date of: 9/2/24. No record of fire drill documented in facility. Washer and dryer observed operational during visit. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature ranging from 111.3 to 113.1 degrees F. in bathrooms 1 and 2. Non-skid mats observed in both bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with outdoor seatings available for residents. 1 out of 4 chairs missing and is in need of purchase. Samples of medications were checked and observed kept locked in the cabinet. Residents’ MARS was reviewed. First aide kit observed with all of the required items.

All residents files and samples of staff files reviewed to have all the required documents.