Facility Evaluation Report

Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Family First Home Care Inc. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver (CG) Martha Shuma. Caregiver Alma San Diego was also present. Administrator (AD) Lisa Derrick arrived later to assist with the visit. The facility is licensed for 6 non-ambulatory residents. The facility has a Hospice waiver for 3 residents. There are currently 6 residents living in the facility. The last emergency disaster drill was conducted on August 14, 2021. LPA Velazquez observed the Complaint poster was not initially present in the facility and AD Derrick located a copy of it but it was approximately "8 x 10." LPA advised AD to obtain the Complaint poster in the correct size pursuant to regulation. The Ombudsman poster was also not posted in the facility and AD advised to prominently display both the Complaint and Ombudsman posters in the entry way of the facility.

At 8:45 AM LPA Velazquez conducted a tour of the physical plant along with AD Derrick. The 1 story home consists of 5 resident bedrooms with 2 bathrooms. The facility also has a living room, family room, dining area, and kitchen. The 6 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails of varying sizes in the resident bedrooms. AD Derrick was not sure if there were written physician orders for the bed rails present in the resident files. AD Derrick proceeded to remove the bed rails on some of the resident beds. One resident had full bed rails and per AD Derrick that resident is not receiving hospice services. Throughout the tour of the physical plant LPA observed there were no auditory alarms present on most of the exit doors which AD Derrick verified. AD Derrick informed LPA Velazquez that 2 residents have Dementia. AD Derrick proceeded to install auditory alarms throughout the facility and LPA Velazquez found them in operating condition. Resident bathrooms were checked. Resident bath towels and personal hygiene supplies were adequately stocked. Toilets and water faucets worked