Facility Evaluation Report

Licensing Program Analyst's (LPA)'s LPA Shawna Doucette and LPA Kamaldeep Kaur arrived at the facility unannounced to conduct an annual inspection. LPA's rang the doorbell and there was no answer. LPA Doucette contacted the Administrator via telephone. Administrator Ana Liza Aratea responded to the facility to meet LPA's to conduct the visit.

LPA's entered the facility with Administrator. Administrator walked directly to the medication cabinet which was unlocked and began locking the medication cabinets which were located in the kitchen. LPA's observed medication in a medication cup on the kitchen counter unlocked and accessible to a resident in the dining room. Staff was not in the kitchen at the time of entry.

A tour of the facility was conducted with the Administrator. The residence was set at 75 F temperature and free of passageway obstructions inside and outside.

Facility had a 7 day non perishable food supply however did not have two day supply of perishable. LPA's did not observe any milk or eggs and food supply was low. LPA's took photos. Facility had food locked in food pantry.

Cleaning supplies were locked in a cabinet above the washing machine. Smoke detectors and carbon monoxide detectors were checked and properly working. Fire extinguishers were charged and had service dates of 06/03/24. LPA checked water temperature which measured at 115.5 F.

Resident, medication and staff records were reviewed. LPA observed medication errors for R1. R1 medication count did not match start date on centrally stored log. Start dates were pre logged for 10/18/24. R1's medication was instructed to be given twice a day and facility was only administering one time per day. Facility was administering medications with no prescription labels. LPA took photos of medications.