Facility Evaluation Report

Licensing Program Analyst (LPA) Debbie Palacios conducted an unannounced annual required visit . LPA met with Clinical Care Director Vanessa Navarro who was informed of the purpose of the visit. Facility was approved for thirty three (33) Ambulatory, fifteen (15) Non-ambulatory, and one (1) bedridden resident; Hospice waiver approved for eight (8) residents. LPA conducted a tour of the interior and exterior of the faciity, reviewed facility documents and conducted interviews. LPA observed the following:

LPA observed the physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies and detergents were stored and inaccessible to residents in care. The sharp and dangerous objects were observed to be locked and inaccessible to residents in the kitchen. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector and carbon monoxide was operational. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Facility receives one shipment of food every week scheduled for Wednesday. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Staff files reviewed include but not limited to have personnel records, health screenings, criminal record clearance, required training, and valid first aid/CPR certification. Resident files included but are not limited to signed admission agreements, pre-placement, personal rights, needs and service plans, and updated physician reports.