Facility Evaluation Report

Licensing Program Analysts (LPA) Lissett Padgett and Darius WIlliams arrived unannounced to conduct the Annual inspection. LPA's met with Administrator, Nancy Montiano (AD) and explained the purpose of the visit. Facility was toured with various staff.

Resident rooms contained required furnishings and lighting. LPA's observed required items in bathrooms. LPA's tested the hot water in three resident rooms with the following results: 129 degrees F, 124 degrees F, 75.4 degrees F . Resident hygiene supplies were properly stored and available. The kitchen was toured observed with necessary items and appliances and sharps/knives were properly stored.

LPA observed required food supply and paper products. LPA observed expired condiments in food pantry. Staff removed expired food items during this visit.

Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. At 10:20am LPA's observed barbed wire hanging low (about 5ft off the ground) on the perimeter fence. Staff explained barbed wire was installed for security measures.

First aid kits are located in office found to contain required items.

Fire Extinguishers are located throughout the facility and were serviced in 3/2024. Smoke and Carbon Monoxide detectors were present throughout facility and operational. Alarms are serviced by Secure Systems. LPA's conducted 6 resident and 6 staff file reviews. 1 staff file did not have documentation of initial training.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 3/22/2024 : Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond .