Facility Evaluation Report

On 04/25/2024 at 8:46 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Jessica Owens and Alex Archangel and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator's certificate expired in January of 2024, and renewal application was submitted to the Department. The renewal application is pending. The facility is licensed for sixteen ambulatory clients only. There are currently fourteen clients who reside at this facility.

The LPA Martinez toured the facility with Jessica Owens on 04/25/2024 at 1:00 PM.

During today's annual inspection ten client files and ten staff files were reviewed. Staff files were complete. Client' 1 Physician report was complete; however, client's 1 tuberculosis chest results were not available at time of visit. LPA Martinez requested a copy of client's 1 chest exam and a copy of the current fire inspection report. Documents will be emailed to LPA Martinez by 5:00 PM on April 25, 2024. A technical violation was given due to not having client 1's chest exam available at time of visit. LPA Martinez reviewed 5 Medication Administration Records (MAR), and MARs were completed and maintained. Facility has a emergency disaster plan and infection control plan. The facility's last fire drill was on April 15, 2024. LPA Martinez reviewed two PNI documents, and the documents were complete and maintained. The facility has liability insurance and surety bond.