Facility Evaluation Report

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director Danny Vera and explained the reason for the visit. Danny Vera's Administrator's Certificate expires on November 14, 2027. Facility is licensed for 76 ambulatory and 122 non-ambulatory of which 122 may be bedridden. Facility has an approved hospice waiver for 20 and there are 133 residents present today with 10 on hospice. LPA and the Executive Director toured the facility. The facility has 4 levels, the ground level (1st Floor) has the main entrance and lobby. There is basement level with an underground parking. The basement level has elevator access and has a game room for residents. LPA observed the facility emergency food and water supply stored in the basement level. The facility has a 3 day supply of food and water for emergencies. Residents reside on levels 1, 2 and 3. LPA observed all stairways have emergency evacuation chairs. All fire extinguishers in the facility were found to be fully charged. There is an outdoor patio on the First floor with shaded seating for the residents to sit outside. There is a pool in the outdoor patio. The pool is surrounded by a 5 foot tall fence with a gate a each end. Both gates are secured. LPA observed residents listening to a speaker in the theater room. LPA observed residents playing cards in the main sitting area in the lobby. The resident library on the first floor has a computer with internet access for dedicated resident use. LPA observed the See Something Say Something poster (PUB 475) in the main entrance of the facility. LPA and the Executive Director toured the kitchen and dining room. LPA observed the kitchen and dining room are clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the walk-in refrigerator in the kitchen was at 38.0 degrees Fahrenheit and the walk- in freezer was at 0.1 degrees Fahrenheit. LPA reviewed the temperature logs for the freezer and refrigerator and the logs are up to date. LPA inspected the medication room on the second floor. LPA observed all medications were secured in the medication room.