Facility Evaluation Report

On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #18-AS-20220715115207. During today's inspection, LPA Colvin observed the following deficiencies, which was reviewed with Administrator Maria Gonzalez:

Care of Persons with Dementia - LPA Colvin observed while at the facility that the auditory alarms on the front door and back door of the facility were switched to the "off" position, and were not alerting staff as to when the door was opened. The facility retains residents with Dementia, including resident (R1) who recently eloped from the facility on 7/4/22. Deficiency cited. Additionally, LPA Colvin observed that R1, who is diagnosed with Dementia, does not have a Physician's Report dated any more recently than June of 2021. The facility is required to have these reports updated at least annually for persons with Dementia. Deficiency cited.

Fire Safety - While LPA Colvin was inspecting the front door alarm, LPA Colvin observed that staff had locked the front door using the deadbolt, which was only able to be unlocked from the inside of the facility with a key. This is an dangerous fire hazard to the residents and staff, as in the event of an emergency, they would not be able to quickly exit the front door unless they had the key on hand. Deficiency cited. Fire safety violations result in an immediate civil penalty in the amount of $500.

Visitor Policy - When LPA Colvin walked up to the facility's front door from the outside, LPA Colvin observed a posted Visitation Policy/Hours, which limited visitation to 9:30am - 5:30pm on Monday - Friday, and 10am - 4pm on the weekends. LPA Colvin did observe an addendum to the hours underneath, which read that these hours could be flexible for family members . This is a violation of resident's rights to visitors, as the hours listed during the week are common working/business hours, and the hours on the weekend are even more severely restricted. Deficiency cited.