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 Christopher Alcayde and informed him 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 107.2 degrees. LPA Colvin observed a large amount of boxes and other items stored along the side of the building. LPA Colvin additionally observed that these items blocked the exit door from Resident One's (R1) bedroom to the backyard of the facility. Deficiency cited. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives and dangerous chemicals were locked in a cabinet in the kitchen, away from residents' reach.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 ambulatory residents. No exceptions or waivers are present at this time.

Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that there is an Administrator present, as evidenced by Administrator being present when LPA Colvin arrived at the facility. LPA Colvin confirmed staff have criminal record clearance and have training to perform their required duties. Staff present have current CPR/First Aid Certification.