Facility Evaluation Report

LPA Shawna Doucette arrived at the facility unannounced to conduct an annual inspection. LPA was granted entry by Staff Paula Maribel Brizuela. LPA explained the purpose of the visit and Administrator Ria Loria responded to the facility to meet LPA to conduct the visit.

A tour of the facility was conducted with the Administrator. The residence was set at 74 F temperature and free of passageway obstructions inside and outside.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication room. Cleaning supplies were in a locked storage room.. Smoke detectors and carbon monoxide detectors are hard wired with a fire panel and pull station fire alarm. Facility has a fire sprinkler system. Fire extinguishers were charged and had service dates of 05/22/23. LPA checked water temperature in 4 resident rooms to all be over 132 F to 146.4 F.

There was outdoor seating for the residents.

Resident, medication and staff records were reviewed. LPA observed a medication error for R1. One of R1's medications was not logged on the MARS or centrally stored log. LPA observed 3 out of the 5 resident to not have a centrally stored log. LPA observed 18 of 120 narcotic PRN medication to be missing for R2. Facility staff did not have the proper annual training. Current first aid and CPR were reviewed.

LPA took photos of medications and water temperature in resident rooms.

A copy of this report with plan of correction and appeal rights were provided to the Administrator.