Facility Evaluation Report

Licensing Program Analysts (LPAs) Emily Peraldi and Sandra Urena arrived at the facility unannounced to conduct a required annual visit. At 8:00 a.m., the LPA was greeted by staff and explained the reason for the visit. At 9:35 a.m., the Director of Resident Care Services (DRCS), Courtney Barber arrived at the facility.

Files: Between 9:25 a.m. and 11:55 a.m., the LPAs conducted a file review for seven (7) residents and seven (7) staff. Resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order.

Starting at 9:35 a.m., LPA Peraldi conducted a review of medication, medication records, policy and procedures with medication technician for ten (10) residents. No errors observed during the medication review.

The LPAs obtained a copy of the resident roster, and staff schedule.

Due to time constraints, the LPA will return at a later date to complete the annual.

Exit interview conducted. A copy of the report was provided.