Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola conducted a continuation annual visit from 2/22/2024. LPA met with Licensee, Jacquelyn White, who was informed of the purpose of the visit.

The facility does not have an infection control plan for inspection. The facility had PPE supplies observed during the visit. The client file had all required documents, the personnel records and training were not available during the visit to inspect. All client medication was locked in the kitchen. LPA reviewed client medication and found medication was being kept in pill boxes and discontinuation order for medication was not on file for Resident #1 (R1). The facility also did not have a copy of the liability insurance for inspection. No disaster plan was available during the visit for review and staff interview stated there was no plan on file or training on this plan. The staff was also not able to state the date of the last drill.

The above issues were cited and a plan of correction was created with the licensee. An exit interview was conducted where a copy of this report along with appeal rights, deficiency pages, lic811, and lic9098 were reviewed and provided to the licensee.