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 Jamielah Fortajada 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 monitoring the residents and staff for symptoms of infectious diseases.

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 observed the facility to be a comfortable temperature and that the hot water in the bathroom faucets measured at 120 degrees. LPA Colvin observed the bathroom sink to have a slow drain while measuring the hot water temperature. Since the water did still drain after a short period, LPA Colvin is only issuing a Technical Assistance (TA) Advisory Note and recommending that the facility look into correcting the slow drain. LPA Colvin did not observe any obstructions to emergency exits or hallways/walkways. 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 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 4 non-ambulatory and 2 ambulatory residents.

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 a certified Administrator present.