Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Jessica Estrada (Wellness Coordinator) and discussed the purpose of today’s visit. Maintenance Director Andy Mendoza arrived shortly after to assist with the inspection. The facility is licensed for 85 non-ambulatory residents, age 60 and over, of which nine (9) may be bedridden. The facility has an approved hospice waiver for twenty (20) residents.

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

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected eight (8) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#216. Staff responded 5 minutes later to assist. LPA Ramirez observed evacuation chairs in stairways. LPA Ramirez observed video surveillance in rooms# 211 & 216. Video surveillance was placed at the request of the residents and family. LPA Ramirez will issue Technical Violation based on this observation.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dinning room servers disinfecting tables and counters while wearing gloves and hair nets.