Facility Evaluation Report

Licensing Program Analysts (LPA) Jose Villalobos and Ashley Calderon conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Executive Director Logan Harrison. The following 12 (CARE) tool domains were utilized during the inspection:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan.

The facility does not have a Dementia Waiver in place. A Hospice Waiver for 10 is approved.

A fire clearance for 75 residents of which (34) may be non ambulatory; 0 may be bedridden.

Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place.

The facility does not have Dementia residents. Facility is a 3-story building consisting of 65 resident rooms, 2 activity rooms, beauty salon, dining room, laundry room, and a courtyard patio area.

The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents.

On 6/15/23, The sprinkler system, alarms, fire connections, and kitchen hood system were inspected. The facility has fully charged fire extinguishers.

Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. LPA tested rooms #103 , #106 , #107, #116, #124, #125, #221, #225, #228, and #231.