Facility Evaluation Report

10/29/2024, 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. LPA was greeted by staff member, Twon Blake. Tanya Barreto, arrived shortly after LPA arrived. Administrator, Sheri Lott arrived later during visit. There are currently 4 clients in care. Facility approved/cleared for 1 non-ambulatory. There was 3 clients present during visit.

At approximately 10:20am, LPA and staff toured the building and grounds. The facility was found to be at a comfortable temperature. 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. LPA noticed the bottom of a corner wall in the bathroom had a small area that was broken/decayed wood. Staff notified LPA he is fixing up around the house and showed previous before and after photos of replacing the kitchen and bathroom floor. As well as a list of what needs to be done around the house, he has planned with the broken/decayed wood being on the list to replace. Water temperature in sinks accessible to clients in care were measured at 118.2 and 117.5 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected August, 2024. Toxins, sharps and other items that could pose threat if available to clients were located in a locked cabinet in the kitchen. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Facility conducts fire/evacuation drills monthly with the last one being done 09/18/2024.

LPA conducted a review of four client records. All records had the required documentation. Cash resources were documented.