Facility Evaluation Report

On 09/11/2024, 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 by facility staff. Facility staff contacted Administrator, Rodrigo Arrieta (AD) via telephone. Administrator arrived a short time later.

LPA reviewed resident records and found the following. Upon review of resident records, LPA observed that R2 needs an updated physician's report and R1 did not have a complete home health agreement on file. Upon review of staff files, LPA found that staff did not have annual training on file for dementia, medication, and restricted health care. LPA requested to review a staff file and AD was unable to provide the file. AD stated that the staff is no longer working for the facility. LPA reviewed facility emergency disaster plan. Per AD, the facility has not conducted a fire/disaster drill.

LPA conducted a tour of the facility with the Administrator. LPA observed the living room/common areas to be clean and appropriately furnished. Dining area was observed to be adequately furnished. The facility kitchen observed to be clean and safe for food preparation. Food supply was checked. Resident bathrooms appeared to be clean. LPA observed securely fastened grab bars, and non-skid mats. Hot water measured 112.6 degrees F. LPA observed disinfectant wipes on the bathroom counter in bedroom 4 accessible to residents in care. Resident bedrooms were toured. LPA observed full bed rails on R3's bed. AD did not have a physician's order on file and R3 does not receive hospice services.