Facility Evaluation Report

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Reynaldo Cruz and explained the purpose of the visit. Administrator certificate is current.

At approximately 8:50AM, LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. The facility was observed to be at a comfortable temperature. First aid kit was present. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas and kitchen were clean and in good repair. A sink drain in a clients bathroom was leaking into a bucket and the counter was separated from the wall. LPA issued a Technical violation. Hot water temperature was within regulation, between 105-120 degrees F. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supply of food. No pools/bodies of water are on the premises. LPA observed a dead bolt lock on an exit door that required a key to lock and unlock from the inside. The lock was in the open position. LPA requested Licensee replace the lock with a style that opens from the inside without a key.

At approximately 9:15AM, Staff and Client files were reviewed. LPA observed 1 of 4 staff files did not contain a completed health screening. 4 of 4 client records contained the required documentation. First Aid/CPR certification was current. All employees requiring background checks are cleared.

At approximately 10:00AM, LPA reviewed medications and medication records. Medication is locked and not accessible to clients in care. LPA observed one medicated cream was transcribed incorrectly onto the medication administration record. The instructions were to apply 3 times daily for 21 days and was written as two times daily however, staff documented it was applied three times daily as ordered. The correct instructions were listed on the centrally stored medication record.