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 Stephanie Olivas and informed her 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, trash cans with tight-fitting lids, and monitoring the residents and staff for symptoms of infectious diseases.

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 observed the facility to be a comfortable temperature. LPA Colvin measured the hot water in three bathroom faucets, and obtained readings of 103.1 degrees (downstairs) and 119.6 degrees (upstairs). Hot water is to be between 105 and 120 degrees. Deficiency cited. LPA Colvin did not observe any obstructions to emergency exits or hallways/walkways. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives and dangerous chemicals were locked in a safe in the locked garage, away from residents' reach.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 3 ambulatory and 1 non-ambulatory resident.

Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that there is a certified Administrator present. LPA Colvin confirmed staff have criminal record clearance and have training to perform their required duties. Staff present have current CPR/First Aid Certification and have other relevant training listed in their files.