Facility Evaluation Report

This facility is licensed to serve thirty four (34) non-ambulatory residents over the age of 60. This facility may retain no more than eight (08) hospice residents. There are two (02) residents under hospice care. The facility is a single-story dwelling located in a residential neighborhood. Total census for this facility is seven (07). Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection. LPA Ramirez met with Administrator Rachel De Chavez purpose of today’s visit. Surveillance cameras were observed in common areas of the facility.

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

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected seven (7) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. LPA Ramirez observed discarded roofing material, shopping cart, several tera cotta bricks, several empty paint bucks, ladder, and broken-down commercial refrigerator in the facility backyard/side parking lot. LPA Ramirez will issue Type B deficiency based on this observation.

Food Service: LPA Ramirez observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).

Planned Activities: LPA Ramirez observed a posted facility activity schedule upon entrance to the facility.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line.