Facility Evaluation Report

Licensing Program Analysts (LPAs) Joseph Alejandre and William Vanegas made an unannounced visit to conduct the required annual inspection. LPAs met with the Executive Director Raymond Pellicer and explained the reason for the visit. The facility has a main lobby and 4 separate wings and each wing has multiple floors. There is a fountain outside the main entrance of the facility. The facility has a memory care unit with delayed egress. LPAs observed the main stairway in the lobby did not have an evacuation chair. LPAs observed there are numerous shaded area with tables and chairs outside the facility for residents to sit outside. LPAs and the Executive Director toured the facility. LPAs observed the emergency food and water is stored in a supply closet. LPAs and the Executive Director toured the kitchen and dining room. LPAs observed the dining room is clean and organized. LPAs observed there is a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPAs observed both refrigerators and freezers had temperature logs posted on the doors. LPAs toured 8 resident rooms. LPAs observed all resident bathrooms in the rooms inspected were clean and operational. Hot water measured between 116.6 and 112.2 degrees Fahrenheit in the rooms inspected. LPAs observed all resident rooms had the required furnishings. LPAs observed multiple rooms for activities and social gatherings. The fireplace in the upstairs living room (plaza lounge) is screened. LPAs observed the See Something, Say Something poster posted on the second floor in a hallway. LPAs observed residents having an ice cream social in the upstairs living room. LPAs and the Executive Director toured memory care. LPAs observed residents participating in a sing a long. LPAs observed emergency evacuation chairs in each stairwell. LPAs observed the signal system in the memory care unit is not operational in any of the 19 rooms. The Executive Director verified the signal system in memory care is not operational. LPAs verified the signal system in assisted living is operational. LPAs observed the delayed egress exits in memory care are operational. LPAs observed the medication is kept locked in a medication cart in the medication room. LPAs interviewed staff and residents. LPAs reviewed 5 staff files. All staff interviewed during the visit and staff members who's files were reviewed are background cleared and associated to the facility. LPAs observed that 1 out of 5 staff members (Staff 4) did not have the required 20 hours of annual training. LPAs reviewed 7 resident files and medications.