Facility Evaluation Report

Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Receptionist/Activity Director Liz Gaggos who allowed entry. Administrator Vicky Torres arrived a short time later and assisted with the inspection today. The facility is licensed for 60 residents ages 60 and over. The fire clearance is approved for 60 ambulatory residents. Last Fire Drill was 09/05/2023 There is a hospice waiver approved for 20 residents.

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

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents with medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance.

Operational Requirements: The facility has plan to accept or retain clients with dementia. There are currently 0 bedridden residents and 37 non ambulatory residents residing at the facility. The facility has enough liability insurance covering injury to residents and guest.

Physical Plant & Environment Safety: The physical plant consists of a lobby, conference rooms, lounge, activity room, dining room, salon, kitchen, kitchenette, laundry room, staff lounge, medication room/nurse’s room, 2 elevators, and outdoor courtyard. The building has 2 floors. The building has delayed egress devices on exit doors to alert when dementia residents exit and were tested during the visit. Smoke detectors were observed in common areas and in each resident bedroom. There are fire extinguishers throughout the building. There are complete first aid kits in the medication rooms. Windows and doors are in good condition and there were no obstructions near doors. Windows do not have security bars. There are 43 bedrooms and 31 bathrooms. LPA inspected 7 random resident rooms, and all had the required furnishings and ample room for storage. There is a combination of private rooms and shared rooms. 1 of the resident rooms were modeled to show shared and private furniture layout. All the bedrooms have sufficient closet space and lighting. The bathrooms in resident rooms have the required grab bars and non-skid materials in the showers. The hot water was tested in multiple bathrooms and was between 110.0 – 114.8 which is within range.