Facility Evaluation Report

Licensing Program Analysts (LPAs) E. Conchas and A. Martinez conducted an unannounced visit to the facility for an annual inspection. LPAs initially met with Licensee Edna Ancheta.

LPAs toured the facility inside and out. The facility has no bodies of water. The facility is equipped with two (2) fire extinguishers, neither of which have updated service tags; last service date is marked as October 5, 2023. A deficiency was cited. The facility had operating smoke detectors and a carbon monoxide alarm. Outdoor and indoor passageways were kept free of obstruction.

The outside of the facility had a shaded area with seating. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. Centrally stored medications were kept in a safe and locked place. LPAs toured the kitchen in which food was stored in a safe and healthy manner. The facility had sufficient food for residents in care. LPAs toured the residents’ bedrooms. The residents’ bedrooms had the required furniture and functional lighting.

The facility had a complete first aid kit. The facility did not have a current emergency disaster drill updated with resident information and did not have record of quarterly drills conducted; a deficiency was cited. The facility did not have an infection control plan available; a deficiency was cited.

LPAs toured the client bathrooms. The bathrooms were operating in safe and sanitary conditions. LPAs measured the hot water temperature in the bathroom. The hot water temperature measured 110.6 degrees F.