Facility Evaluation Report

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue annual inspection. LPA met with Administrator Daisyree Tacandong during today's inspection.

During today's inspection LPA toured the facility and the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 2 of 6 resident files and 3 staff files. LPA reviewed medications of two residents comparing with physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA observed a copy of current liability insurance.

During today's inspection LPA observed the following deficiencies:

2 of 3 staff members did not have a health screen on file.

During annual inspection on 5/25/23, staff files were not available for LPA to review.

Administrator did not have a Centrally Stored Medication Record for 2 of 2 residents.

R1 and R2 did not have a needs and service plan.

LPA observed medication for R1 was not being dispensed as the doctor ordered.

LPA observed a closet in resident bathroom being used as a staff break room.

Deficiencies cited on 809-C. Exit interview completed.