Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Dawnyell Varela - Director/Administrator and explained the purpose for today’s visit.

The facility is a RCFE - Continuing Care Retirement Community that is licensed to serve individuals, age 60 and above. Fire clearance is approved for two hundred and fifty-two (252) ambulatory, one hundred and six (106) non-ambulatory, and ninety-six (96) bedridden. The facility may accept or retain ten (10) hospice residents. Census during inspection was fifty-five (58) residents in assisted living, two (2) in memory care, and two hundred and fifty-one (251) residents in Independent Living.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.

Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, Care of Bedridden Residents Plan and training, and facility maintains the required liability insurance.

Physical Plant & Environment Safety: LPA toured facility, a total of 10 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom that are operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees.