Facility Evaluation Report

Licensing Program Analysts (LPAs) Cuadra and Rummonds made an unannounced required annual inspection of this facility and met with facility acting Administrator Erlinda Ferris. Annual fees current.

LPAs/Administrator toured the building and grounds which was found to be clean and in good repair. The main building is two stories and currently there are seven residents residing upstairs. Second building is single story and currently there are two residents. At approximate 10am LPAs/Administrator did not observe assigned staff in the second building providing care and supervision to resident in care who has a non-ambulatory status as indicated in their facility plan of operation. Assigned staff was walking into the second building as we were touring the facility. LPAs reminded the Administrator the requirement to have an assigned staff at all times in the second building to assist residents in care. Administrator could not provide a reasonable explanation regarding the absence of assigned staff in the second building. Medication is centrally stored and locked in medication cart and closet. A sample of medication and medication records reviewed. Facility has cameras is both buildings in common areas. However, at approximate 10:05am LPAs/Administrator observed cameras located in private room #2 and 26. Per Administrator, resident's responsible parties brought the cameras without permission. LPAs/Administrator also smelled several bathrooms has a strong urine odor. LPAs/Administrator did not observe any CCL's reports placed in a conspicuous place. Also, the facility does not have required CCL complaint poster. A technical violation will be issued.

At approximate 10:30am LPAs/Administrator observed hot water measurements of 129.3, 132, 145.2, 136 and 146.8 degrees which is not within regulation between 105 and 120 degrees F at faucets used by residents in care. Fire extinguishers inspected were charged and dated 4/5/2024. Smoke detectors were tested in resident rooms. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present. The last disaster drill was conducted on September 27, 2023.