Facility Evaluation Report

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Maria Zuniga and explained the reason for the visit.

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

LPA toured the facility along with Administrator Maria Zuniga today 11/21/2023 at 1:40 PM and the following was observed:

Facility contains 56 Client Bedrooms dining room, and TV room.

LPA inspected Rooms 113, 117, 123, 128, 129, 137 and 138 and the water temperature measured between 105 F- 120F.

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 3 staff and 5 clients. 7 client files were reviewed and 7 staff files 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.

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 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.

First Aid for staff was not current for 7 staff files reviewed.

Deficiency cited on the 809 D. Exit interview conducted and copy provided.