Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Interim Executive Director Nicole Long.

The facility is licensed for a maximum capacity of 70 non-ambulatory residents, 6 of which may be bedridden. The facility has a waiver for 15 hospice residents. During today’s visit, the facility had a census of 42 non-ambulatory residents. The Administrator for the facility is Katrina Jimenez and their certificate was valid and current.

During today’s visit, LPA toured the facility and inspected a random sampling of resident bedrooms and bathrooms, common bathrooms for general use, facility kitchen, common areas, and outside space. LPA observed small water fountains located within the facility's enclosed courtyards. LPA observed delayed egress on facility exit doors in accordance with the facility's fire clearance approval. LPA did not observe any aspects of secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 118.0, 118.4, and 118.6 degrees Fahrenheit in a random sampling of resident bathrooms. The facility’s internal temperature was measured at 70, 72, and 74 degrees Fahrenheit across the facility. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Nicole Long, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at -2 degrees Fahrenheit.