Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Required Annual Inspection on this date. LPA met with Nellen Van De Sol, Administrator and was informed of the purpose of the visit. Administrator was able to assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. Facility is licensed for 6 beds with a fire clearance for 6 ambulatory, 2 non-ambulatory, 0 hospice, and 0 bedridden residents. Current census is 6. Administrator certificate is current and expires on 10-8-22.

LPA toured the facility and reviewed the Mitigation Plan as well as discussing Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures. Smoke alarms and carbon monoxide detectors were tested and were operable. LPA toured resident rooms which contained all appropriate furnishings and accommodations. LPA also inspected the living room and family room areas. 7 days of non-perishable, and 2 days of perishable food items. Staff accommodations are located off of kitchen area. Fire extinguisher was fully charged. Sharp objects and toxins were inaccessible to residents in care. LPA observed adequate amount of linens available for residents. Medications were locked and secured. Facility temperature measured at 74 degrees F. Hot water temperature measured 115.2 F degrees in kitchen area. First aid kit was accessible and stocked appropriately.

LPA reviewed (3) staff charts. All necessary components were present and updated including required training. All staff are fingerprint cleared and associated to work in the facility at this time. LPA reviewed (6) resident charts. All necessary components were present and updated including admission agreement.

LPA observed the following posted in the facility: See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. LIC 500, LIC 308, LIC 610E were requested to be submitted to Licensing within 30 days.

As a result of this inspection, no deficiencies were cited.

Exit interview was conducted with Administrator and a copy of report was given at the conclusion of the visit.