Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Aurelia Olais and discussed the purpose of the visit.

The facility has two buildings, resident bedrooms, resident restrooms, kitchen, dining room, activities room, laundry room and outdoor patio. LPA observed residents watching tv, engaging in activities and eating lunch during the inspection. All resident bedrooms had the required components and furnishings. LPA observed the resident restrooms to be stocked with toilet paper and paper towels. LPA observed the shower rooms to have textured shower flooring. LPA tested the water to be between 105.2 and 115.7 degrees Fahrenheit in the resident restrooms. LPA observed the kitchen to be clean and free of vermin. LPA observed a two day perishable and seven day nonperishable food supply on hand. LPA observed the kitchen door to be locked making the kitchen inaccessible to residents in care. LPA observed the medication counter to be locked and made inaccessible to residents in care. LPA observed the first aid kit to be located in the medication room and complete of all components. LPA observed the centrally stored medication to be in locked medication carts and made inaccessible to residents in care. LPA observed the emergency food and water supply to be located in the staff office building. LPA observed the toxins and chemicals to be in the facility garage and made inaccessible to residents in care. LPA observed the laundry room attached to the staff office to be locked making the chemicals inaccessible to residents in care. LPA observed the patio area to be free of obstructions with shaded seating for resident use. LPA observed the delayed egress gates to have a 15 second delay with a less than 30 second response time from care staff. LPA and AD tested the signal system and it was found operational with staff responding within a minute of it being activated. LPA observed fire extinguishers throughout the facility charged and with a service date of April 18, 2025. LPA and AD tested the carbon monoxide detector in the dining room and it was found to be operational. Continue on 809C