Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual inspection. LPA met with Penafranci explained the purpose of the visit. Later joined by Jean Briones

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112.9 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers, smoke detectors and carbon monoxide detector are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs.

During the file review it was discovered that R1 does not have a package for home health services, including: Foley catheter maintenance (last records indicated that the catheter was changed on 3/16/2022), medications management and positioning

(currently facility staff are turning R1 every two hours). R1 graduated from Hospice on 3/13/2022(?) no records to support this date. LPA reviewed 4 resident and 2 staff files, including criminal record clearances.