Facility Evaluation Report

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility Executive Director Rebecca Toves, after identifying herself and stating the purpose of the inspection. This facility serves one hundred fourty five, residents 60 and above. Hospice waiver approved for fifteen.

A tour of the facility was conducted which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There is a water features in the courtyard made inaccessible to residents. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Overhead as well bedside lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant.

The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in each building. Emergency lighting, and facility telephone were all working. First aid kit(s) were complete and readily accessible in the medical rooms. Required licensing postings were observed in visible areas of the facility. PPE supplies are onsite. Indoor passageways were free from obstructions.

Food supply is replenished frequently by outside vendors. Food was observed to be properly labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts. Medications were labeled and kept in compliance with label instructions.