Facility Evaluation Report

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Jessica Lopez caregiver and explained the reason for the visit.

The facility is licensed to serve (6) bedridden residents ages 60 and over. The facility is located in a residential area behind another home, and consist of a dining room, living room, kitchen, (3) resident bedrooms, (2) resident bathrooms, a back yard, a garage, and a shared front yard and laundry area.

The following domains were reviewed during this visit:

Infection Control : Facility does not have a copy of infection control. All staff have a TB clearance.

Operational Requirements: Facility maintains a plan of operation, fire clearance. Facility is operating within the limitations of their license. They currently don't one resident under hospice care. A current liability insurance was observed and a copy was obtained.

Physical Plant/Environmental Safety: LPA toured the facility with Jessica Lopez caregiver and observed the following. Facility was observed in good repair. Living room and dining room were observed with furniture and in good repair. Kitchen was observed clean. Cleaning supplies and sharps are maintained in a locked cabinet. Refrigerator/freezer and pantry were observed. Medication cabinet is located in hallway. Three (3) resident rooms were observed with sufficient lighting, required furniture and bedding supplies. Exit doors in each bedroom exiting the facility have a sound device that were observed not working at the time of the visit. Bed rails were observed in each residents' bed. Resident #1 and #3 have 3/4 bed rails and there is no physician's request on file. Two (2) bathrooms were observed in good repair and clean. Water temperature was tested in each bathroom sink and tested between 66.7 - 103.4 degrees F., which is not within the required 105-120 degrees F. (CONTINUED ON LIC809C)