Facility Evaluation Report

Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Denise Sutton, Supervisor. LPA discussed the purpose of the visit. The facility is licensed to serve 124 non-ambulatory residents over the age of 60, with a hospice waiver for 16 residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and and an Infection Control Plan.

2. Physical Plant and Environmental: The facility is in a residential area and consists of a multi-level building with a dining room, library area, a commercial kitchen, resident rooms, a medication room, two (2) courtyards, a patio, a smoking area in the first floor. The second floor has a seating area, a TV room, an activity area, and several resident rooms. There is a total of three (3) stairwells. The baseman consists of staff offices, a therapy room, a laundry room, a beauty parlor, and staff break rooms. Each resident' room has a private bathroom. LPA inspected the carbon monoxide/smoke detectors in random rooms and are working probably. Facility tested the general fire alarm during the visit. LPA tested the hot water temperature, and tested between 109.9 –117.3 degrees F. which are within the Title 22 regulation of 105.0 – 120.0 degrees F..All the cleaning supplies and chemicals are locked and inaccessible to residents. The facility has sufficient personal hygiene products for clients to use. All clients rooms are completely furnished with chairs and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway are safe and free of obstruction. One of the eaves by the stairway #3 leading outside needs to be repaired (continued on 809C)