Facility Evaluation Report
Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced One (1) year Required visit at this facility. LPA met with the administrator designee Khristine Campbell who granted access and LPA explained the purpose of the visit. The facility is a single-story dwelling with six (6) bedrooms of which five (5) are for resident use. The facility has an approved fire clearance for five (5) non-ambulatory and one (1) bedridden resident in Room #5 for a total capacity of 6. The facility has a Hospice waiver for two (2) residents.
While the administrator assisted residents with breakfast LPA reviewed two (2) of two (2) resident records to insure compliance with licensing forms. Records are kept locked in a kitchen cabinet. Centrally Stored Medication and Destruction Records were reviewed for proper documentation. Medication records are maintained manually. Facility keeps Medication Administration Records (MAR) as well.
A tour of the physical plant was conducted at 11:00 a.m. with the administrator designee and the following was observed: There is only one entrance being utilized at the facility, there are required postings posted by the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, and masks are available.
Kitchen: LPA conducted a tour of the kitchen and observed there to be sufficient supply of two day perishables and seven day non-perishables foods, properly stored. Food storage and preparation areas are clean and clear of clutter. LPA observed all knives, sharp object, locked in a kitchen drawer inaccessible to residents in care. There is one (1) fire extinguisher located in the kitchen observed to be fully charged with purchase date 04/30/2024. LPA observed the first aid kit with manual up to date in a kitchen drawer.
Common areas: LPA observed the living area and dining area to be clean. The furniture was in good repair and sits the capacity of the facility. Breakfast nook also stores games and crafts for residents to use.(Continue to LIC809-C)
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction