Facility Evaluation Report

Licensing Program Analyst (LPA) Nicole Spencer conducted a Case Management - Annual Continuation visit. LPA Spencer was greeted by lead caregiver Cristal Parra and explained the purpose of today's visit. The initial annual visit was conducted on 11/24/21. During the initial visit, the entire physical plant was toured. During today's visit on 11/29/21, staff files, client files, and medications were reviewed.

The facility had a universal entrance screening area; sign-in log, screening logs, and temperature logs were maintained.

COVID-19 signage was placed in several areas of the facility including the front entrance.

On 11/24/21, there was a sufficient 2-day supply of perishable foods but an insufficient 7-day supply of non-perishables as there were no canned fruits. On 11/29/21, a sufficient supply was observed.

All areas were found to be clean and in good repair.

On 11/24/21, LPA observed that cleaning solutions and sharp knives were placed in an unlocked cabinet. A staff member immediately locked it.

Each room contained required furniture including bed, dresser, night stand, lamp, chair, and closet.

All beds contained the required linens including mattress cover, fitted sheet, flat sheet, blanket, and comforter.

Hot water temperature was measured and was not within the required 105-120 degrees F. On 11/24/21, hot water temperature measured between 81.3-96.5. On 11/29/21, hot water temperature measured between 124-131 degrees F.

Facility maintained a 30-day supply of PPE to include masks, gowns, and face shields.

Smoke detectors/carbon monoxide detectors were present and operable.

Oxygen tanks were observed to be secured on stands.

A fire extinguisher was observed to be fully charged and last serviced in June 2021.

Medications were given as prescribed by the physician. Facility maintained 30-day supply of meds.