Facility Evaluation Report

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Lydia Pabion, Administrator and explained the reason for the visit.

Facility is licensed to serve 99 adults over the age of 60 years old, of which 35 may be non-ambulatory. Facility has a hospice waiver for 4 and the following rooms are cleared for bedridden residents; 102 thru 110, 115 thru 119, and 123. LPA observed the following today:

1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and but does have an Infection Control Plan.

2. Physical Plant and Environmental: Facility is a two-story building with a commercial kitchen, a dining room, an activity room, a courtyard, a medication room, a laundry room, front porch, and smoking area in the back. LPA inspected the carbon monoxide/smoke detectors in random rooms and are working probably. LPA tested the hot water temperature, and was tested between 105.4 –121.5 degrees F. which is not within the Title 22 regulation of 105.0 – 120.0 degrees F. All the cleaning supplies and chemicals are locked and inaccessible to residents. The facility has sufficient personal hygiene products for clients to use. All clients rooms are completely furnished with chairs and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway are safe and free of obstruction. One soap dispenser is in need of repair, room 105 is missing slip mat, some window screens need repair, and one shelf in storage room needs replacement. Small trash can first floor restroom needs repair.