Facility Evaluation Report

Licensing Program Analysts (LPA)'s Shawna Doucette and Sarah Hurt arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's met with Administrator Alma Espinal.

LPAs toured the facility inside and out. LPAs observed adequate food supply. Smoke detectors and carbon monoxide detector were tested and are in working order. Facility has pull station fire alarm with sprinkler system. Fire extinguishers were serviced 2/10/25. Water temperature measured at 120 F.

LPAs observed the following deficiencies:

R1 did not have a completed LIC 602. LPA's viewed several required boxes missing required information.

R2 did not have a current needs and service plan.

R3's physician report was not complete and was missing diagnosis. R3 did not have a current LIC602 for change in condition R3 went on hospice. Facility did not have a hospice care plan for R3.

LPA observed a sample of resident's medication and medication records. R3's medication 1 started on 5/1/25. Pill bottle originally contained 30 pills. R3 has 8 pills left. R3 is missing a pill or it was administer twice in a day. Prescription indicates it should be administered once daily. R3's medication 2 started on 5/1/25. Pill bottle originally contained 30 pills. R3 has 7 pills left. Facility is missing or administered 2 of R3's pills.