Facility Evaluation Report

Licensing Program Analyst (LPA) arrived at 12:00 pm to conduct a 1 year annual visit to the facility above. LPA met with Administrators Roxandra Whitestine and Rachelle Tellez LPA explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE).

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on April 2025. The facility is approved for a capacity of 22. The fire clearance is granted for 22 Non-Ambulatory of which 18 may be bedridden and Hospice is approved for 8.

Physical Plant & Environment Safety: The fire extinguishers were last charged and inspected on May 9, 2024. The facility is a 17 resident bedrooms currently occupying 15 residents and employs 20 staff and 2 Administrators. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in cupboards and closets. The facility has sufficient space inside and outside for activities and visiting. The facility has plenty of shade. The facility has telephone and internet service for resident use.

Staffing: LPA will return at a later date to review staff files.

Personnel Records & Staff Training: LPA will return at a later date to review staff training records