Facility Evaluation Report

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit at the facility regarding deficiencies noted on 2/20/24. LPA met with Anita Savage and explained the reason for the visit.

On 2/20/24 LPA Flores conducted an unannounced annual visit and noted the following deficiencies:

Section CCR 80087(g) - Building and Grounds - During the visit on 2/20/24 LPA observed cabinet under the sink with cleaning and disinfecting solutions unlocked. 3/5/24 LPA observed cabinet locked at the time of the visit. Deficiency cleared as of 3/5/24.

Section CCR 80088(e)(1) - Fixtures, Furniture, Equipment, and Supplies - During the visit on 2/20/24 LPA tested water temperature in bathroom #1(downstairs) tested at 124.7 degrees F., and bathroom #2 (upstairs) tested at 129.2 degrees F. 3/5/24 LPA tested water temperature in both bathrooms and tested at 115.1 degrees F., which is within the required temperature. Deficiency cleared as of 3/5/24.

Section CCR 85064(k) - Administrator Qualifications and Duties - During the visit on 2/20/24 during file review administrator's HIV/TB training was not on file. On 3/5/24 certificated for HIV/TB taken on 4/28/23 was observed. Deficiency cleared as of 3/5/24.

Exit interview was conducted with Jana West and a copy of this report was provided.