Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 11:07 AM. LPA met with facility staff who contacted the facility’s Assistant Administrator Gabriella Chavez. The Assistant Administrator arrived to the facility at approximately 11:10 AM, entrance interview conducted and the reason for the visit was explained. The following was observed.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the

facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The infection control plan is reviewed/updated annually by the facility’s Administrator. Emergency disaster drills are conducted monthly; the facility’s last emergency disaster drill was conducted on 02/07/2025. LPA observed the facility to be utilizing an out-of-date LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly. LPA informed the Assistant Administrator that the form was out of date and that the facility should be utilizing an LIC 610D, Emergency Disaster Plan For Adult Community Care Facilities and Residential Care Facilities For The Chronically Ill, as the facility is licensed as an Adult Residential Facility (ARF). The Assistant Administrator stated that they are aware and the facility is currently working on completing an updated LIC 610D. The Assistant Administrator stated that they would send a copy to CCLD once it is completed.

MEDICATION REVIEW: Medication review began at 11:45 AM. Medications for five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.