Facility Evaluation Report

On 01/12/2024 at 10:00 am, Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced one (1) year required visit for this facility. The facility is currently on a 2 year non-compliance plan. LPA informed the Administrator the purpose of the visit.

Infection control: LPA reviewed facility mitigation plan (approved on 01/30/21) to make sure the Administrator was following current infection control recommendations.

A tour of the physical plant was conducted with the Administrator at 10:15 am. The facility has five (5) bedrooms, with one (1) room designated for live in staff, and two (2) bathrooms currently occupying three (3) clients. Two (2) clients were observed in the living area watching TV and one (1) client was in day program.

Food Inspection: LPA conducted a tour of the kitchen around 10:15 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects being double locked and inaccessible to clients in care. At 10:17 am LPA observed medications to be locked and inaccessible to clients.

Resident Rooms: LPA observed all rooms to have the appropriate bedding. There is a night stand, chair, and sufficient lighting for each bedroom.

Bathrooms: At 10:25 am LPA observed all bathrooms to have non-skid matts, grab bar. Hot water was tested and measured within regulation at 116.9°F.