Facility Evaluation Report

On 8/18, at 11:30 pm. Licensing Program Analyst (LPA) Noel Wolf Petersen arrived unannounced to follow up with some changes to policy the facility was asked to make as part of a previous Plan of Corrections. LPA met with the adminstrator Jean Alvarez and explained the purpose of the visit.

A-Toxics under the sink are now locked in the locked staff room.

A- All staff are firgerprinted and associated via gaurdian

A- medication training is complete for most employees, current MARs are up to date with available medication, but PRN documentation records are not up to date, the LPA is writing a new citation for it.

B- 2 days of Perishable Food is in compliance, 7 days of non-perishable is in compliance

B- Continuing training is complete for non-dementia folks which the citation was refering to, one resident does have dementia now, therefore extended dementia training is required, and the LPA is writing a new citation for asking that training to be completed.

Administrator following documents were reviewed:

License: The License is for 6 non-ambulatory, there is one person who is bedridden in the facility currently, and the last fire clearance says 4 non-amb and 2 bedridden, dated 12/6/22. The LPA will ensure the license gets updated and sent to the administrator.