Facility Evaluation Report

01/02/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required.

At approximately 9:35am, LPA and Program Manager toured the building and grounds. The facility was found to be at a comfortable temperature and passageways were free from obstructions. Facility has a pool in the backyard that is fenced and inaccessible to clients in care. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 111.2 and 111.0 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 05/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients were located in a locked drawer in the kitchen and in a locked pantry. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of 4 client records. All records had the required documentation. Client cash resources were reviewed.

LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

LPA followed up on an incident report that was submitted to CCL on 11/25/2024. Incident Report states Client 1 (C1) was walking out of their room when their knees buckled causing C1 to fall. Staff called program manager to inform them about C1's fall and C1s foot and knee were swollen. Staff then took C1 to the emergency room where they took x-rays and facility was told C1 broke his foot in three different places. Facility made all appropriate notifications per regulation.