Facility Evaluation Report

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Bella Navalta and explained the reason for the visit.

The purpose of the visit is to complete the required inspection.

LPA toured the facility along with Staff Bella Navalta today 01/28/2024 at 9:20 AM and the following was observed:

Facility contains 4 Client Bedrooms and 2 Client Bathrooms, dining room, living room, and TV room.

Annual Inspection includes the following Domains:

Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights- Information, Client Records- Incident Reports, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness.

Interviews were conducted with the 1 staff on duty. 1 client was interviewed and 3 client's were attending Day Program.

4 client files were reviewed and 1 staff file were reviewed. All staff were cleared and associated.

Medication was administered per physician's directions.

Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.

Licensee maintained an individual admission agreement for each client.

Fire Clearance has been maintained. Water temperature measured 105 F.

Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations.

Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.

There is not an adequate number of direct care staff to support each resident's physical, social, emotional safety and health care needs as identified in his/her current appraisal.

Hallway light leading to client rooms was not operating and it was dark in the hallway.

Smoke Detector audibly stated low on battery.

Deficiencies cited on the 809 D. Exit interview conducted.