Facility Evaluation Report

On 7/27/24 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to complete the annual inspection. LPA met with Licensee Lita Williams.

On 7/9/24 LPA observed the following deficiencies:

Smoke detectors were not present in the home, Administrator was not able to provide verification the sprinkler system is in working condition.

Gardening tools were in an unlocked drawer in kitchen which are accessible to residents in care.

Toxins and cleaning supplies were stored in a cabinet under the sink and in a cabinet next to the sink which was unlocked. The garage also has cleaning supplies which was not locked.

Canned food and additional refrigerators are stored in the garage area which is not clean and has rodent droppings throughout the garage.

Garage is used to store food which is not being maintained.

Garage area used for additional kitchen is not being maintained.

Food is not being stored or labeled properly.

Medications are not being logged on the centrally stored medication log.

There are no audio alarms on the exits and dementia residents reside in the facility.

Staff use R1's room to go outside to throw the trash.

Staff member S1 was at the facility without being properly associated to the facility. LPA observed staff at the facility.

Staff member S2 was on the staff schedule and was working NOC shift according to Licensee.

Licensee will provide insurance verification by 8/6/24. Citations were issued per Title 22.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator Lita Williams.