Facility Evaluation Report

On 09/13/25, Licensing Program Analysts (LPAs), L. Salazar and M. Garza arrived at the facility unannounced to conduct the required annual visit. LPAs were greeted by staff, stated the purpose of the visit and were allowed entry into the facility. Staff called Administrator, who was available via telephone.

LPAs toured the facility inside and out including entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. LPAs observed 3 residents in care at the time of visit. Facility is a 4 bedroom 2 bathroom home. Bathrooms were observed to have grab bars by the toilets and a grab bar in the shower used by residents. Resident bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction. Facility temperature was 76 degrees F. Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 110.4 degrees F. Smoke detectors were tested and observed to be operational. Fire Extinguisher was observed with a service date of 09/17/24. First aid kit was observed and contained all required items. Required postings were observed for Non-discrimination LGBTQ-A+, Personal Rights of Residents in RCFE and theft policy. No residents are receiving Hospice services residents or receiving Home Health care service.

The following issues were observed during todays visit: LPAs did not observe posting of facility's visitation policy, LETUSNO Complaint Poster, (PUB475) and Ombudsman poster. A sample of 7-day food source was observe to be expired. Oxygen was observed in master bedroom closet, unsecured and not on a stand. R1's file showed R1 had a hospital visit on 08/20/25 that was not reported to CCL. There have been zero incident reports submitted by facility in 2025. Resident records were reviewed. 2 out of 2 files to have blank forms in the file. Blank forms were Identification & Emergency information (LIC601), Pre-admission appraisals (LIC603), Personal Rights of residents in care (LIC613C2), personal property and valuables (LIC621), Centrally stored medical and destruction record (LIC622), Appraisal/Needs service plan (LIC625), and Consent for medical treatment (LIC627C). Staff record were reviewed. 1 of 3 staff files was missing from facility. 2 of 2 staff files observed to be incomplete: Health screening report/TB testing (LIC 508), missing training hours (initial/ongoing). (Continued on LIC 809C)