Facility Evaluation Report

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced required annual visit. LPA met with Assistant Administrator Gloria Gibson and explained the purpose of the visit. Villa Luren is licensed to serve 62 mentally disabled adults, 6 may be non-ambulatory. The facility is single story & consists of 3 wings LPA toured all 3 wings with Ms. Gibson and observed the following:

Resident rooms, bathrooms, dining hall/TV area, medication room, kitchen, laundry room, 2 offices, and outdoor covered patio areas. The facility is equipped with a sprinkler system. The last fire drill was completed on 3/28/2024.

As a part of the inspection, LPA reviewed a (6) client records, (4) staff files, and (6) client medications. LPA toured facility and observed that toxins and sharps locked and inaccessible to clients. Bedrooms are equipped with a (2) beds each, a dresser, lamp, chair, overhead lightning for each client. The facility bedrooms have bathrooms which have a working toilet, wash basin, and bath/shower. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies were observed. Facility has sufficient amount of perishable and non perishable food. Fire alarms are interconnected and operational. Smoke detectors and carbon monoxide detector tested and operational. Water temperature within required title 22 regulations, measured at 108 degree F.

Deficiencies cited on 809-D. An exit interview was conducted and a copy of this report, and appeal rights provided to Ms. Gibson.