Facility Evaluation Report

Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Assistant Administrator Caitlin Hildalgo and LPA explained the purpose of the visit. Administrator Melissa Flores arrived a short time later. The facility has a capacity of 34 residents. It is licensed to serve elderly residents age 60 and above, approved for 34 non-ambulatory residents. Facility is approved for 8 hospice waivers. The facility cares for elderly residents with dementia. Administrator certificate is current and expires on 8/12/2023.

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, mask and gloves while assisting residents with medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies.

Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility does not have proof on file of enough liability insurance covering injury to residents and guest.

Physical Plant & Environment Safety: The facility is in a residential neighborhood and consisted of 17 resident’s bedrooms, 13 bathrooms, living room, kitchen, dining room, activity room, medication room, and activity area at the patio. Facility has operable fire alarm and sprinkler system; Knives are inaccessible to client. There was toilet cleaner bleach in the bathroom of one resident room. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms sink. The hot water temperature in the measured between 126.3 degrees F which is not between the required range of 105-120 degrees. Door by the activity room needs repair. The rails along the common hallway are in disrepair. Debris room 7 shower need to be removed. Windowsill in room is uncleaned.

Staffing : There appears to be sufficient staffing at the facility. Staff employed are all over the age of 18.

Personnel Records-Training : Staff files are maintained at the facility. Some staff no not have current CPR/first aid training and no evidence of on-going training.