Facility Evaluation Report

Licensing Program Manager (LPM) Lizzette Tellez and Licensing Program Analysts (LPAs) Juliana Barfield and Adrian Mangina conducted an unannounced continuation visit for a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to and discussed the purpose of the visit with Casey Villas. Administrator Kathleen Marquez arrived during the visit.

According to the facility’s license, the facility has a maximum capacity of six (6) residents, all of whom may be non-ambulatory. One resident may be bedridden in bedroom #6. During today’s inspection, there were a total of four (4) residents in care. This facility does not feature delayed egress doors.

LPM and LPAs, accompanied by Ms. Marquez, toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas.

During the inspection LPA observed two bedridden residents (R1-R2) residing in rooms not cleared for bedridden residents. The facility has fire clearance for one bedridden resident. Disinfectants were observed in an unsecured cabinet accessible to residents in care. Exterior exit gates and inside exit door were observed to be locked with padlocks and key operated deadbolt. Tour of the facility bathroom revealed shower mats were missing from two of three bathrooms, and a toilet seat was missing from one toilet. During facility record review, the administrator was unable to produce documentation or date of the last drill. During resident room tour, an oxygen in use sign was not posted in the appropriate area. Additionally, the facility houses residents with major neurocognitive disorder who present a risk of wandering and had disabled the auditory devices.