Facility Evaluation Report

On 08/24/2023, Licensing Program Analyst (LPA) A. Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self, stated the purpose of the visit and was allowed to enter the facility by facility staff. Facility staff contacted Administrator, John Nobleza via telephone. Administrator arrived a short time later.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 118.0 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 07/17/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted 07/2023. All cleaning supplies are locked in a cabinet in the garage. First Aid Kit contained the required supplies.

LPA reviewed staff and client records. Upon review, LPA did not observe a needs and services plan for 6 out of 6 residents in care. R3 did not have a restricted health care plan on file. House care plans for 3 out of 3 residents were incomplete. Hospice records were observed to be missing training for assigned staff. Medications reviewed. LPA observed that R1 was receiving an over the counter medication that had not been prescribed by a physician. LPA observed an pre-dosed insulin injection pen to be in the refrigerator accessible to persons other than employees.