Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 11:32 AM to conduct an unannounced Case Management visit at the facility today. LPA met with facility Administrator Lala Soghonyan. The LPA advised the Administrator of the reason for the visit.

During the physical plant tour at 11:36 AM LPA observed the sliding door in the living room of the facility to be missing an auditory alarm. LPA informed the administrator who agreed to install a replacement alarm. At 11:40 AM LPA observed the living room pantry to contain three (3) expired and/or damaged food cans as well as one (1) unsecured box of prescription lancets. LPA informed the administrator who secured the items immediately. At 11:52 AM LPA observed an unsecured shed in the back of the facility. LPA observed the shed to contain tools, cleaning supplies and extra care supplies. LPA informed the administrator who agreed to secure the shed. At 02:40 PM LPA observed the facility’s first aid kit. The kit was observed to be missing Sterile first aid dressings, bandages or roller bandages, scissors, tweezers, and a current version of a first aid manual. The entire property is not fenced and is connected to three (3) adjacent properties. A certificate of occupancy was requested for this property a nd the adjacent three (3) buildings on the property.

During file review at 12:18 PM LPA observed four (4) of five (5) resident files to be missing signatures on documents including but not limited to: admission agreements, consent forms, identification and emergency contact information, appraisal needs and services, and property and valuables. LPA informed the administrator who agreed to get the signatures of the responsible parties of each resident on all identified forms. LPA observed one (1) staff file to be missing the required annual trainings. LPA informed the administrator who agreed to conduct the required trainings with the identified staff member.