Facility Evaluation Report

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Cynthia Garcia and was granted entry to the facility.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, one (1) resident may be bedridden. The current census is six (6) residents. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA found that the facility has two (2) residents (R3 and R6) in care with a condition that requires auditory alarms on exterior exit doors. The facility does not have auditory alarms on all the exterior exits. The facility will be issued a deficiency for not having auditory alarms on the facility exit doors. LPA measured and observed the water temperature in the bathrooms to be at 110.8 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. The non-perishable and perishable food supply is sufficient for the residents in care.

During kitchen tour, LPA found cleaning supplies, toxins, and sharps were not kept inaccessible to residents in care. LPA found bleach in an unlocked cabinet underneath the kitchen sink, found knives in a knife container on the kitchen counter, and found knives in an unlocked drawer in the kitchen. The facility will be issued deficiencies for not properly locking the chemicals and for not properly locking the knives.