Facility Evaluation Report

On 9/25/2024 Licensing Program Analyst (LPA) B. Miranda arrived unannounced at the facility listed above to conduct a continuance of the Annual Inspection which was originally started on 9/20/24. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA met with staff Muang Saechao who stated they are in the process of becoming Administrator. Caregiver Heidy Campos was at the facility and the annual inspection was completed with her.

LPA has been to the facility multiple times and current administrator Lucy Leang has not been at the facility. Interviews were conducted and some interviewees stated they did not know nor have they met the listed Administrator. Administrator was also not listed on the schedule Staff Maung Saechao provided. Current and valid administrator’s certificate was not provided. LPA did not observe documentation for emergency drills that were conducted at the facility.

LPA observed medication to not be stored in original containers and to be stored in weekly pill planners. LPA reviewed a sample of files and R2’s file did not have current PRN form with correct medications. Residents with a DX of dementia should have a medical assessment and reappraisal completed annually, LPA reviewed sample files and found R1 to have their last medical assessment 9/21/2020. On 9/20/2024 LPA observed a cabinet in the dining area to be unlocked with medication accessible to residents.