Facility Evaluation Report, 10/17/2023 — Broken Arrow Home, Norco CA

0905: Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. LPA learned there is one client residing in the home.

0935: Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA reviewed one client record. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Records were complete. P&I ledgers were reviewed and money counted. Accurate ledgers are maintained.

0950: Physical Plant and Safety of Environment/Operational Requirements/Food Service: LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature. Lighting is sufficient for safety and comfort. Water temperature measured 105.0 degrees F. Grab bars, non slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of perishable and 2 day supply of non-perishables food on hand. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand.