Facility Evaluation Report

On 12/11/23, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility to conducted an unannounced Case Management-Annual continuation visit to continue with the Annual visit initiated on 12/6/23. The LPA met with Bernadette Descargar, Administrator on record, and explained the purpose of today's visit. During this visit there are 5 residents in care with 3 staff on duty.

During this inspection, LPA conducted an audit of facility files, 5 resident files, and 6 staff files for regulatory compliance. All staff noted on LIC 500 have criminal background clearances and are associated to this facility. LPA attempted 2 resident interviews, however, residents were not available for interviews. LPA also completed 2 staff interviews. 5 out of 5 resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. 5 out of 5 staff files reviewed contained all required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required trainings. Facility’s liability insurance is current per regulatory requirements. The facility is current on annual license fees. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills.

Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. The facility maintains for each resident Centrally Stored Medication, Destruction Record and PRN Log. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed facility to have sufficient equipment and supplies to meet activity program needs of residents in care.