Facility Evaluation Report

Licensing Program Analyst (LPA) Jose Villalobos conducted an announced required annual inspection. LPA met with Administrator Tricia Pedroza and stated the purpose of the visit. LPA conducted annual inspection using the Infection Control Domain Tool.

The facility consists of 5 buildings, the main building and 4 cottages. There are two levels in the main building, 4 single story cottages (E1-E4) and covered patio area on the grounds. The main structure has 23 bedrooms, men's and women's bathrooms on lower and upper levels, a dining room, kitchen, living room, office and a laundry room. E1 consist of 6 bedrooms and one bathroom, E2 consists of 4 bedrooms and one bathroom, E3 consists of 4 bedrooms and one bathroom and E4 consists of 3 bedrooms and one bathroom.

On todays visit LPA followed the Infection control domain, toured the physical plant, reviewed eight (8) client and six (6) staff files, and the medication records for eight (8) clients. LPA observed required amount of perishable and non-perishable food items, fully stocked first aid kit, sufficient linen supplies, hygiene supplies, security cameras located in common areas, required postings were observed. The facility has a total of 2 elevators, one in each building and were operational. Fire alarms, carbon monoxide detectors and the signalling systems are interconnected and notify the fire department when triggered. Toxins and sharps locked and inaccessible to residents. Fire extinguishers fully charged. Facility has an approved mitigation plan as of 3/3/21. There was no pool or bodies of standing water observed in the exterior of the facility property. Exits and passageways were free of obstructions. Physical plant clean and free of debris. Infection control domain completed.

No deficiencies are cited at the time of this visit. Exit interview was conducted and a copy of the report provided to administrator Tricia Pedroza