Facility Evaluation Report

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Verly Frias and informed him of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include soap and paper towels at hand washing stations and tight-fitting lids on trash cans.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 109.5 degrees. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed multiple chemicals in the cabinet under the sink, which was unlocked. Deficiency cited. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. Knives are kept locked up and away from resident reach.

Operational Requirements: The facility has a licensed capacity of 6 non-ambulatory residents. Facility has a hospice waiver for 2 residents. LPA Colvin observed that Resident One (R1) is bedridden, and the facility does not have bedridden fire clearance. Deficiency cited. Violations of a facility's fire clearance result in an immediate civil penalty of $500 , which LPA Colvin will be assessing today. LPA Colvin additionally notes that she cited the facility for the same violation on 8/27/21 during a Case Management Visit. P art of the Plan of Correction was that the Licensee/Administrator submitted a Statement of Understanding that they are not permitted to accept or retain bedridden residents without proper fire clearance.