Facility Evaluation Report

On 02/24/23, Licensing Program Analysts (LPA) Lizeth Villegas conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met by Administrator Martha A. Flores to explain the purpose of today’s visit. The facility is licensed to operate for 4 non-ambulatory residents ages 18 through 59.

The facility is a single story 4 bedrooms, 2 common restrooms, laundry area, dining area, kitchen,pantry, linen closet, 1 staff office , a designated outdoor shaded area and a detached garage that stores additional hygiene products, extra PPE and extra linen. The facility has a working landline, 1 phone in the dinning area, 1 phone in the kitchen and 1 phone in the staff office.LPA toured the physical plant and there were no bodies of water or obstructions on the premises.Resident rooms were inspected, beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked during the visit. All bathrooms were found to be within Title 22 regulations and were clean and operational. The facility water temperatures measured between 105- and 110-degrees F. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. All storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. LPA reviewed Medication Administration Records (MAR) revealed to be accurate and maintained in order. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of Fire Drills was observed to be maintained in order and accurate, the last fire drill and disaster drill were on 01/23/2023. During the visit, LPA observed the facility's infection control practices. LPA observed there were screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings and observed the facility to have a 120-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved CCLD Mitigation Plan. The facility has submitted an Infection Control Plan to the regional office.

There are no deficiencies cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Martha A. Flores