Facility Evaluation Report

Licensing Program Analyst's (LPA)'s Shawna Doucette and Daiquiri Boyd arrived at the facility unannounced to conduct an annual inspection. LPA's were granted entry by Staff Normita Garcia. Staff contacted Administrator via telephone who responded to assist with the visit.

A tour of the facility was conducted with the Administrator. The residence was set at 73 F temperature and free of passageway obstructions inside and outside.

Facility had a 7 day nonperishable food supply and two day supply of perishable foods. Cleaning supplies were locked in a cabinet above the washing machine and under the kitchen sink. Smoke detectors and carbon monoxide detectors were checked and properly working. Fire extinguishers were charged and had service dates of 05/29/25. LPA checked water temperature which measured at 106.6 F. Medication was locked in a kitchen cabinet.

Resident, medication and staff records were reviewed. Facility was administering an over the counter medication that was expired and not prescribed by physician for R1. Facility staff are utilizing a hoyer lift for R1 and do not have training. Staff are not logging resident responses for R1's PRN's that are administered.

Facility does not have restricted health care plans for R2's restricted health condition. R2's LIC 602 states resident cannot do own injections or glucose testing. R12s LIC602 states R2 requires special diet. Staff do not have training for restricted health conditions. R2 and R3 do not have current Home Health Care Plans. R4 does not have a Home Health Care Plan. Facility staff do not have training for R2 and R3 restricted health conditions.