Facility Evaluation Report

Licensing Program Analyst (LPA) Shira Stamps met with designee Shella Villar for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:30am and was greeted by caregiver Shella Villar. The Administrator was contacted at 10:40am, and LPA spoke to the Administrator and informed her of the purpose of the visit. The Administrator was out of town over 45 minutes away, and designated caregiver Shella to sign the report. One (1) resident was observed in the living room resting. The rest of the residents were observed to be in their room sleeping, watching TV and/or resting.

A tour of the physical plant was conducted with the Designee at 10:53 am. The facility has six (6) bedrooms and two (2) bathrooms currently occupying five (5) residents. One (1) bedroom and one (1) bathroom is designated for staff use only. The facility is Fire Cleared for five (5) non-ambulatory and one (1) bedridden.

Infection control: LPA reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA was asked to sign-in and sanitize/wash hands.

LPA conducted tour of the kitchen around 10:55 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 appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed a child squeeze lock on the cabinet under the kitchen sink. The cabinet obtained three (3) bottles of chemicals/ cleaning solutions and disposable needles. The Designee immediately locked the hazardous items in the garage. LPA observed all knives and sharp object being locked and inaccessible to residents in care in the locked hallway closet along with the resident’s medications. CONTINUED...