Facility Evaluation Report

On 10/8/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual inspection. LPA Jensen met with Administrator Arlene Acuavera and Co-Administrator Romel Acuavera and explained the purpose of today's visit.

LPA Jensen inspected the grounds. The front yard has a full gate. All paths were free of obstruction. There are no bodies of water. The window screens are in good repair. The fence was observed to leaning. There was also various pieces of wood along the fence where repairs had previously been attempted. The backyard fence is now in need of replacement. There are shaded areas available for outdoor activities. LPA Jensen toured the interior and observed the facility to be sanitary. There was adequate furnishings throughout the common areas. The facility maintains in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. The food in the freezer was not labeled. Technical assistance was provided. There are fresh fruits and vegetables available. Dinner was being prepared and consisted of mashed potatoes, meat loaf, carrots and fruit salad. There was a variety of snacks and beverages available. The fire extinguisher was last serviced on 11/27/23 and is in compliance. The carbon monoxide detector was tested and found to be in good working order. There are flash lights available for emergency use. The water temperature was within the required range. The thermostat was set at 73 degrees for the comfort of the residents.

The facility is licensed for 4 non-ambulatory residents and 2 ambulatory residents. LPA Jensen reviewed the facility sketch, the fire clearance and the resident roster. It was learned that resident 6 (R6) is non-ambulatory but occupying an ambulatory room. It was also learned through a resident file review that Resident 2, who occupies a non-ambulatory room, has a restricted health condition care plan (RHCCP) dated 11/1/23 that states R2 "is unable to to turn/reposition without assistance from staff". The LIC 602 is dated 12/27/22 and states R2 is non-ambulatory. The Licensee has agreed to obtain a new LIC 602 to verify the ambulatory status of R2 and submit to the department.