Facility Evaluation Report

On 02/16/2024, Licensing Program Analyst (LPA) 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. LPA requested to meet with the Administrator. LPA met with Administrator, Stephanie Haro.

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 had required furnishings. LPA observed small holes in the walls in bedroom 1 and bedroom 2. LPA observed water damage to the ceiling of bedroom 2. 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 129.7 degrees F in bedroom 1, 129.3 degrees F in the bathroom near bedroom 3, and 126.5 in the bathroom near bedroom 4 and 5 LPA also observed water damage to the hallway ceiling near bedroom 4 and 5. Kitchen toured. LPA observed an adequate food supply. LPA observed that the refrigerator shelving needs to be repaired and a light bulb needs to be replaced. Exterior tour conducted, all exits open and free of obstructions. LPA observed an outdoor fan needing to be cleaned.

Fire extinguisher serviced on 10/10/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 12/14/2023. All cleaning supplies were observed to be locked and inaccessible to residents in care.

LPA reviewed staff and client records. Upon review of records, LPA found that 5 out of 5 residents did not have a needs and services plan. LPA found that multiple residents did not have signed admission agreements, and R3 did not have an admission agreement for the above facility. Medications reviewed and observed to have original labels and be administered as prescribed.