Facility Evaluation Report

Licensing Program Analyst (LPA), Victoria Chitgian, made a visit to the facility to conduct an annual licensing inspection. Analyst was granted entry into the facility and met with Frank Pesqueira, Administrator. A tour of the facility was conducted. Licensee is providing each consumer with clean linen in good repair, and sufficient hygiene products for personal use. A comfortable temperature is maintained in the facility at the time of visit. The last disaster drill was conducted on 4/26/23. Hot water temperature in the bathroom measured at 117 degrees F. Kitchen water temperature was measured below required limit of 105. LPA issued Technical Violation. The facility is stocked with a two (2) day supply of perishable and seven (7) day supply of nonperishable food items. Food is being prepared and stored properly. Medications are stored in a locked closet in the hallway and administered according to the label instructions. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care. All staff have a criminal record clearance, however First Aid certificates were not available for viewing. Deficiency issued. Administrator has secured each consumer’s personal property and cash resources. Each consumer file was reviewed. Records contained Admission Agreement, ambulatory status, however one client did not have a tuberculosis test result, as required. Deficiency was issued. The Administrator is on the premises a sufficient number of hours to adequately administer the facility in compliance with applicable law and regulation.

The facility did not have a written disaster and mass casualty plan to review. Administrator stated there must be a plan in place the main office, however there is not a copy at the physical facility. Deficiency was issued. LPA did see a floor plan posted in a common area along with other required signs and postings, such as the visitation policy.

Based on today’s inspection, four (4) deficiencies were observed at this time in the areas evaluated. One technical violation for the water temperature. An exit interview was conducted and this report, LIC 809, LIC 809-D, LIC 9182 and appeal rights was provided to Administrator Frank Pesqueira at the end of the visit.