Facility Evaluation Report

On 10/13/2022 at 10:30am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual infection control visit. LPA Pascua was greeted by Administrator, Monica Arroyo and explained the purpose of the visit. The purpose of the visit is to conduct an annual infection control visit. This facility is licensed to hold 6 ambulatory residents and is vendorized by Valley Mountain Regional Center to hold Level 4I residents at this time. The current census was 5. There was two other staff members at the time of this visit, Colleen Garcia and Lourdes Jimenez.

Administrator holds a current Administrator certificate #6044527735 and is valid until 11/06/2023.

At 10:40am, LPA Pascua initiated a tour with Administrator Arroyo.

At 10:45am, The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

At 10:50am, A tour of the kitchen was conducted. LPA Pascua observed a sufficient amount of 2-day

perishable food supply in the refrigerator and a 7-day non-perishable food supply in the pantry for 5 residents. Knives were observed to be locked and made inaccessible to the residents at this time. Cleaning supplies were also observed to be locked under the kitchen sink and made inaccessible to the residents in care. A fire extinguisher was also observed to be in the kitchen and was annually inspected by Nor Cal Fire on 10/13/2022.

From 10:55-11:05am, LPA Pascua observed a locked centralized stored medication cabinet located in a locked closet under the stairs. Along with the Administrator Arroyo, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

At 11:10am, LPA Pascua toured the garage. Additional food supply was identified in the refrigerator located in the garage. Additional toiletries were also identified.

At 11:15am, LPA Pascua toured bathroom #1 and was observed to be in good repair. Hot water temperature was measured to be 106 degrees.