Facility Evaluation Report

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Clinical Director Yolanda Torres. According to the facility’s license, the facility has a maximum capacity of 68 residents of which 41 may be non-ambulatory with a hospice waiver for 10. The facility is comprised of 6 stand-alone buildings, with two memory care areas both approved for secured perimeter.

LPA toured the interior and exterior of the facility and inspected multiple rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Water temperature in residents rooms were measured all between 105 degrees F to 119 degrees F. There are no bodies of water present. A few mattresses required replacing and Clinical Director agrees to have them replaced.

LPA toured and observed the commercial kitchen and walk-in refrigerator. The kitchen was clean, organized and sanitary. Cooking/dining equipment and utensils were present. There was sufficient perishable food and at least two weeks worth of non-perishable food.

LPA observed multiple medication carts and first aids were complete and readily accessible. Medications were labeled, as required, and stored in locked medication carts. Resident records contained the required documentation. Staff records contained the required documentation. LPA reviewed care staff first aid refresher training's within the facility training system. Per Clinical Director, no firearms or ammunition are kept at the facility. Fire extinguishers were readily accessible in each cottage and have been serviced within the last year. No deficiencies were cited on todays visit. An exit interview was conducted with Clinical Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to during the visit.