Facility Evaluation Report

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff contacted Administrator (AD) Leilani Alejandro via telephone who arrived a short time later and was present for the visit. AD Alejandro has a current administrators certificate that expires 12/02/23.

At 9:05 AM LPA Haley and staff began the inspection at the entrance of the facility. Three clients were present during the visit. A screening station with hand sanitizer and screening logs was observed right next to the front door. Above the screening station a fully charged fire extinguisher was mounted on the wall. Next to the screening station near the front door there's a closet used as a pantry. Inside the pantry LPA observed chips, coffee, and other non-perishable food items.

Clients bedrooms were clean, organized, and had all necessary requirements: night stand, chair, lamp and storage space. At 9:25 AM, LPA observed in client bedroom #3 a sheet covering a portion of the wall. Behind the sheet, the wall is exposed and you can see the insulation and studs. The client bathroom was clean and organized. Hot water temperature was measured at 109.2 degrees Fahrenheit. In the hallway cabinets between the living room and client rooms LPA observed a supply of clean linen and a emergency bag with non-perishable food items, clothing, a first aid kit and other items. Client files and medication records are locked in a file cabinet in the hallway. Next to client bedrooms 1 and 2 LPA observed two locked cabinets with plenty of clean towels and bed sheets.

In the dining room LPA Haley observed a small table set up for staff in the corner, and locked cabinets used to store client medication and a supply of non-perishable food items. In the kitchen LPA observed a 2 day supply of perishable food items and a 7 day supply of non-perishable food items in the cabinets above the counters. All burners on the stove were operational.