Facility Evaluation Report

Licensing Program Analysts (LPA) Rachel Bruce and Melinda Medina arrived unannounced to conduct the Annual inspection. LPA's explained the purpose of the visit and allowed entry into facility by care staff. Staff provided a tour of the facility while waiting for Administrator, Nancy Montiano (AD) to arrive.

Facility tour and inspection revealed the following:

Resident rooms contained required furnishings and lighting. LPA's observed required items in bathrooms. LPA's tested the hot water in one empty resident room and temperature was within regulatory requirements. The kitchen was toured and LPAs observed necessary items and appliances along with sharps/knives which were properly stored. There was sufficient supply of food per regulatory requirement.

Medications are centrally stored and locked however LPA noted there was a resident prescription unlocked and accessible in the kitchen. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. Chairs located outside client doors are in need of repair or replacement.

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

Fire Extinguishers are located throughout the facility and observed to have current service date. Smoke and Carbon Monoxide detectors were present throughout facility as well as a functioning alarm system. Alarms are serviced by Secure Systems and were last serviced on February 28, 2025.

LPA Medina conducted resident and staff file reviews and will document on separate report.

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 will be provided to AD.

LPA is requesting the following documents be submitted to the Fresno CCL office by 4/15/2025 : Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Lpiability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond .