Facility Evaluation Report

Licensing Program Analyst (LPA), Stephanie Martinez, conducted a continuation of an unannounced required annual inspection at the facility. The LPA met with Executive Director (ED), Brooke Abrego-Huerta, and informed her of the purpose for the visit.

Physical Plant / Environmental Safety: The LPA conducted a tour of the facility, accompanied by the facility maintenance director, Sammy Ortiz. The LPA observed the alarm system in all three (3) buildings to show, "system normal". Two (2) carbon monoxide devices were inspected in the two hundred and four hundred halls and observed to be operable. The LPA inspected three (3) bedrooms in both memory care buildings and four bedrooms in the assisted living building. The LPA observed a chair(s) to be missing in room 8 and 27, and 109; a night stand to be missing in room 27; and a drawer to be missing from the chest of drawers in room 22. These violations were addressed at the time of the LPA's visit. Therefore, an advisory notice will be issued. Bedrooms had sufficient lighting for resident needs. Resident bathrooms were observed to have grab bars available and slip resistant material present in the showers. The toilet, handwashing, and bathing facilities were all in working condition. The hot water temperature was tested and observed to be within regulatory requirements. The call system was tested and observed to be in working order. The LPA inspected and observed sufficient space for storage of supplies and equipment. Storage areas were observed to be appropriately secured for the safety of the residents in care. There are no pools or other bodies of water located at the facility. According to ED, Abrego-Huerta, there are no known firearms being stored at the facility. The facility does have a working telephone available for resident use.

Staffing: Staff have current First Aid/CPR training on file. Separate staffing is available to perform independent tasks for the operation of the facility. According to ED, Abrego-Huerta, all personnel working in the facility are at least 18 years of age. Emergency training is provided to staff members who work the night shift. ED, Abrego-Huerta, is present at the facility during normal working hours and a manager has been observed to be responsible for the operation of the facility when the ED is temporarily absent.