Facility Evaluation Report

Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced visit to the above facility to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 1:15 p.m. The last annual conducted at this facility was on 7/23/2021. Upon arrival, the LPA was greeted at the door by staff, Alexie Rodriguez and Bryce Colvard, and the reason for the visit was explained. The LPA was advised the Clinical Director was unavailable to come to the facility. The Director of Nursing, Wendy McMain arrived at 1:30 p.m., and the Chief Clinical Officer, Sharon Volner arrived at 1:41 p.m. Entrance interview.

At 1:33 p.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed the hallway closet where all medications and staff/client files are locked and inaccessible to clients. BEDROOMS: The LPA observed the clients rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting. RESTROOMS: Client restrooms are clean and sanitary and in operating condition. Restrooms are sufficiently stocked with hand liquid soap and paper towels. There are three (3) bathrooms for client use. Bathrooms were measured for hot water, the first bathroom measured at 120.2 degrees Fahrenheit at 1:39 p.m., the second bathroom measured at 122.4 degrees Fahrenheit at 1:40 p.m., and the third bathroom measured at 111.2 degrees Fahrenheit at 1:43 p.m. Staff adjusted and corrected the water temperature during visit.