Facility Evaluation Report

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Lorena Alandy and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations, hand washing guides posted, and tight-fitting lids on trash cans.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 118.9 degrees in the master bathroom and 124.1 degrees in the hallway bathroom. Deficiency cited. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives were locked away from residents' reach in a drawer in the kitchen. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. LPA Colvin observed cameras in the common areas of the facility, which are not included in the facility's Plan of Operation. Deficiency cited. LPA Colvin informed Administrator/Licensee of items that needed to be addressed in the updated Plan of Operator for the use of cameras, as well as them needing to add a consent form to their Admissions Agreement.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents, one of which may be bedridden. Facility has a hospice waiver for 6 residents.