Facility Evaluation Report

Licensing Program Analyst (LPA) Javina George conducted an unannounced visit to the facility for the purpose of conducting a 1 year required visit/annual inspection. LPA George met with Caregiver Grace Romero and informed her of the purpose of today's visit. The Administrator was unable to come to the facility during LPAs visit. Below is a summary of what was observed during today’s inspection:

Infection Control: LPA observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents.

Physical Plant: LPA toured the interior and exterior of the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. The facility was observed to have the required furniture and linen to be present and in good condition in resident bedrooms. The exits are free from obstruction and that there is plenty of space for activities. There are no pools or bodies of water on the premises.

Staff Records Review: LPA verified staff present at the facility to have criminal record clearance and to be associated to the facility. LPA observed facility staff to have received initial training, but no subsequent or refresher training's to confirm they are able to perform their required duties. In addition staff present was observed to have have expired CPR/First Aid Certification as 5/13/24. Deficiency cited. The administrator certificate expires on 12/5/24.

Resident Records Review: LPA conducted a review of all 3 resident files and observed for required information present in their files, such as Physician's Report, Admissions Agreement. However no updated appraisals to have been present or completed. Deficiency cited.

Food Services: The kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware were present for resident’s use. LPA observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items. In addition the facility was observed to have 18 expired food items ranging from salad dressing to cake mix, crackers and seasoning, rice and pudding. Some of the expiration dates go as far back as November 2014. Deficiency cited.