Facility Evaluation Report

On 11/20/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. Administrator, Marc Barcelona, is not able to attend this inspection. LPA met with assistant Administrator, Myat Tusaw.

LPA reviewed facility records and found the following: Upon review of resident records, LPA found that 3 out of 4 residents did not have a needs and services/care plan on file. Facility did not have records available to review for 2 out of 2 staff on duty. LPA did not observe initial/annual training in the employee training file for 2 out of 2 staff on duty. Emergency disaster plan was not updated. Last documented fire drill was conducted on 01/22/2024. Medications reviewed. LPA found multiple medications not stored in their original container and stored in zip-lock bags. LPA observed multiple over-the-counter medications being administered to residents in care, facility did not have a prescription or documentation showing the medication was authorized by a physician. Fire extinguisher was last serviced on 03/26/2024.

LPA conducted a facility tour with Assistant Administrator. Common areas were observed to be furnishing and had adequate lighting. LPA toured resident bedrooms. Bedrooms observed to have required furnishings. LPA toured facility bathrooms. Hot water measured at 99.3 degrees F. LPA observed a bottle of Clorox disinfectant wipes accessible to residents in care under the bathroom sink. Kitchen toured. LPA observed an adequate food supply. LPA observed the cabinet under the kitchen sink to be unlocked. The cabinet stores cleaning supplies including Ajax that were accessible to residents in care. LPA observed the medication cabinet to be unlocked and accessible to persons other than facility staff. LPA observed an adequate supply of linens.

Exterior tour conducted. Exits were open and free from obstructions during today's inspection. CONTINUED TO 809C