Facility Evaluation Report

Licensing Program Analysts (LPA's) Tremayne Barra and Abdoulaye Zerbo arrived unannounced to conduct an annual inspection. Upon arrival LPA's were greeted by facility staff and granted entry after signing in. LPA's began inspection with introduction and the purpose of the visit. Upon arrival LPA's learned that one-hundred and fifteen (115) residents live at this facility. The Executive Director, Janae Orona was advised of the annual and conducted and completed the facility tour.

Residents Records/Incident Reports/Residents Rights Information: LPA's reviewed residents' records. Ten (10) records were reviewed. LPA's reviewed the identification and emergency information, the admission agreement, the medical assessment, the TB test results, the needs and service plans, the placement, the functional assessment, the centrally stored medication/destruction records, the safeguard for personal property/valuables, and the personal rights notification.

Personnel Records/Training/ Staffing/ Administration : LPA's reviewed Ten (10) employee records including first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current Administrative organization. The Administrator’s certificate expiration date was 03/26/2026.

Food Service: Food preparation areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. Sharps are located in the kitchen and inaccessible to the residents in care .