Facility Evaluation Report

On 10/29/2024 at 12:50 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Assistant Administrator Mary Gonzalez was informed of the visit and met with LPA Brown. At the time of the visit there were 90 residents present.

The facility is a seventy-five bedroom and eighty (80) bathrooms with a kitchen/dining area, living room, beauty shop, laundry room. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred twenty-five (125) non-ambulatory residents and with an approved hospice waiver for ten (10) and the current census is 90 residents. LPA Brown was accompanied by Assistant Administrator Mary Gonzalez to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean with a water temperature of 107 degrees Fahrenheit and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide detectors were observed. Fire extinguishers were also observed at the facility. Posters such as personal rights, ombudsman poster, labor laws, and the disaster plan were posted in a common area. However, LPA Brown did not observe the CCLD complaint poster. Technical Violation will be issued. During the visit, Assistant Administrator Gonzalez posted the required CCLD poster. LPA Brown tested the call button/pull cord on five (5) residents room and observed the call button/pull cord in good working condition. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. ***Continuation in LIC809C ***