Facility Evaluation Report

Licensing Program Analyst Shawna Doucette (LPA) arrived at the facility unannounced to conduct a Required Annual inspection. LPA met with Administrator Nora Rodriguez Lopez and was granted entry into the facility by staff.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen toured, appeared clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Resident rooms checked. LPA observed an adequate supply of linen. Hot water measured at 1230.3 degrees F. Facility was set at 73 F.

Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching and operating.

Fire extinguisher serviced on 10/14/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Medications were stored at another location off site.

Staff files and resident files were reviewed. Medications were reviewed. R1's medication started on 8/19/24 and was directed to be administered once daily containing 200 pills. After conducting a pill count, R1 has 98 pills left and should have 61 pills left.

Facility does not have plan of operation at the facility. Administrator will submit plan of operation by tomorrow for LPA to review.

An exit interview was conducted with the Administrator and a copy of this report, plan of corrections and appeal rights were provided.