Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with both Health Service Director Laura Sanchez and Administrator Jose Speede, and explained the purpose for today’s visit. The facility is licensed to serve 119 non-ambulatory residents of which 15 may be bedridden in rooms 151-155,213,215-217,219,224-227 and 229. Facility has an approved delayed egress and a Dementia Care Plan and a Hospice Waiver approved for (38) residents. There are currently (30) residents receiving hospice care.

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

Infection Control: The facility maintains the required Infection Control Plan.

Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and Care of Bedridden Residents Plan. The facility maintains the required liability insurance that expires on 11/1/26.

Physical Plant & Environment Safety: LPA toured facility, a total of 8 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom that were tested an operating properly. Residents have call pendants that were also tested and operable. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the resident private bathrooms and measured within the required range of 105-120 degrees. The facility had the required personal rights and complaint posters posted. (Continued on LIC809-C)