Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff. The facility is without an active Administrator, The current certificate for Tanya Barreto expired on 5/1/2023.

LPA and Staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. During the tour LPA observed missing screen in the back yard by the garage, tall grass in the front of the facility and in the backyard, the exit door from the garage to the back yard is blocked with a sign saying do not use (fire clearance violation), broken shower grab bar, extreme dust build up on the vents for the filters in the and a broken toilet seat cover. LPA also observed unlocked toxin in R1's room and in the top hall cabinet (The locking device is broken and cannot lock) .

LPA and Staff measured the hot water temperature in residents bathroom at 117 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguisher and Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. medication logs.

First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducts fire/disaster drills with residents on 4/2023. Deficiencies cited with civil penalties assessed.

Exit interview conducted and appeal rights given