Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon arrived at 11:30 am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Kylan Reynoso and explained the purpose of the visit.

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

Infection Control: The facility has submitted a current Infection Control Plan to CCL. The facility has EPA approved disinfectants spray and cleaners. The facility has trash cans/bins with covers. The facility has a 30 day supply of PPE. PPE and infection Control Training is done annually. All sinks have soap, paper towels, hand washing signs.

Physical Plant & Environment Safety: The facility is a 3 bedroom and 2 bathroom home currently occupying 3 residents and 8 staff, including one administrator. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility is fully fenced around the backyard with a self closing and latching gate. The facility has a patio with furniture and umbrella for shade. Laundry room has working washer and dryer.

Operational Requirements: The Facility is operating in compliance with fire clearance. The facility is cleared for 4 non-ambulatory with a Hospice wavier granted for 4. The facility liability insurance expires 09/01/2024.

Staffing: The facility employes 7 staff and 1 Administrator. Staff records are kept confidential. Staff records were reviewed for 5 staff. 3/5 Staff records reviewed had fingerprint clearance and associations, personnel record or application, First Aid and CPR certificates and Health screening with TB results. 7/8 staff had current first aid and cpr card verified. One staff will not work until it is renewed. 2/8 staff had current CPI cards.

Personnel Records & Training: The facility keeps confidential files for each staff member. The facility staff are not meeting the required hours and subjects for initial and annual training and are currently scheduled to take all required training's for 2024.