Facility Evaluation Report

Licensing Program Analysts (LPA) Helena Rummonds and Jacky Macias arrived unannounced at approximately 9:00AM to conduct an Annual Required inspection and was greeted by staff. LPAs and staff discussed the purpose of the visit. Administrator, Yvette Morgan arrived shortly after.

LPAs and Administrator initiated a tour of the facility around 09:35 AM and made the following observations: Facility was at a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 113, 114, and 115 degrees F which is within the range of 105 to 120 degrees F allowed per regulation.

Extra hygiene products and linens were available. LPAs observed bleach, lysol, and other various hygiene supplies in the unlocked garage (deficiency cited, see 809D) . Laundry detergent was observed in a cabinet equipped with an unsecured padlock. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is stored in the garage. Personal Protective Equipment is stored in the garage.

Fire extinguishers were last serviced 4/25/2024. Facility smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 03/13/2024. Five staff files and five resident files were reviewed. S1 does not have a Health Screen on file. Staff have required First Aid and CPR certificates. Medications and medication records were reviewed. Centrally Stored Medication List is currently not updated (deficiency cited, see 809D) .