Facility Evaluation Report

LPA Shawna Doucette arrived at the facility unannounced to conduct an annual inspection. LPA explained the purpose of the visit and met with Administrator Judith Barajas.

A tour of the facility was conducted with the Administrator. The residence was set at 72 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 cart in the kitchen. Cleaning supplies were locked in a cabinet under the kitchen sink. Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguisher was last serviced 11/27/24. LPA checked water temperature which measured at 114.5 F. Fire drill was last conducted 12/1/24.

Resident, medication and staff records were reviewed. R2 missed evening medications on 12/13/24. LPA did not locate any notes as to why the evening medications were not administered to R2. R2 did not have a home health care plan or any information as to how often Home Health is coming to the facility to care for R2's condition. Current first aid and CPR were reviewed.

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