Facility Evaluation Report

During Licensing Program Analyst (LPA) Crystal Colvin's inspection at the facility to conduct an inspection. During this inspection, LPA Colvin observed the following violations which needed to be addressed:

Physical Plant: During the inspection, LPA Colvin observed a cabinet near the washing facilities containing cleaning supplies, including bed bug spray, to be unlocked. Deficiency cited. LPA Colvin additionally observed a mattress in the backyard to be obstructing a exit from the building (sliding glass door). Deficiency cited. This is a violation of the facility's fire clearance and warrants an immediate civil penalty in the amount of $500, which LPA Colvin will be issuing today. LPA Colvin was unable to access a copy of the facility's Plan of Operation, as it was located in a locked staff room which was inaccessible to LPA Colvin during today's inspection (though the Administrator was able to email LPA Colvin what she needed). Licensing is to have access to all areas of the facility at any time, and inability to inspect any room/area results in a d eficiency and immediate civil penalty of $500, which LPA Colvin will be assessing today.

Personal Rights: During record review and interviews, it was revealed that on some occasions (including 2/11/24) that Resident One (R1) will request to make a call to family members and is denied by staff due to family requesting that the resident not call until at least 10am. LPA Colvin inquired as to if there is any documentation of this request from family, and Facility Manager Lorena Guillan denied any such records. LPA Colvin additionally reviewed R1's most recent Individual Program Plan (IPP) and did not observe any mention of this behavior or of it being deemed as inappropriate and the facility staff needing to address it in a specific way. Therefore, denying R1 from making a call when requesting to is a violation of R1's personal rights. Deficiency cited. LPA Colvin learned through interviews that R1 has been sleeping on a mattress in the living room for the last week while R1's room is being treated for bed bugs. LPA Colvin additionally observed in the daily notes for R1 that R1 has not been able to take a nap during the day, due to staff moving the mattress during the day and R1 not having a location to sleep. Deficiency cited.