Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection. LPA met with Administrator, Suzie Magpayo, and explained the purpose of the visit. The facility is licensed for (280) non-ambulatory residents ages 60 and over. There is a hospice waiver approved for 8 residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: The facility is a 4-story building with resident rooms on each floor. The first floor consists of the main lobby, dining room, kitchen, lounge, activity room, conference room, medication room, and resident rooms. The 2nd, 3rd, and 4th floors consist mainly of resident rooms, activity rooms, and laundry rooms. The facility also has a Wellness Center. LPA selected 12 rooms to inspect: rooms #112, #125, #131, #210, #215, #231, #312, #322, #335, #404, #424, #428. The bathrooms have non-skid mats. 8 out of the 12 rooms had the hot water temperatures measured at over 120 degrees F. Smoke detectors and carbon monoxide detectors are operable. Facility has sufficient space to accommodate indoor and outdoor activities. There are planned activities daily. Sufficient food supplies of 2-day perishable and a week of non-perishable items are observed. Facility is continuing to follow their infection control plan and using appropriate hand hygiene while assisting residents. Per the administrator, there is sufficient staffing for each shift based on care needed.

LPA reviewed six (6) personnel files. The administrator's certificate expires on 8/10/2027. Staff have current CPR & First Aid certificates. Staff are receiving annual training. A total of ten (10) resident files were reviewed and all contained the required documents including TB test results. Medications are centrally stored and locked in the medication room. Medications are administered as prescribed. Facility has an Emergency Disaster Plan and is being reviewed annually. Drills are being conducted at least quarterly for each shift.

A deficiency is being issued today. An exit interview was held and a copy of this report and appeal rights were given to the Administrator.