Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon arrived at 2:15 pm to conducted a Case Management Annual Continuation visit to the facility above. LPA met with Licensee/Administrator Joe Castillo and explained the purpose of the visit.

LPA returned to the facility to complete the annual visit. LPA reviewed staff files, Staff Training Records and conducted interviews on staff and residents in care.

Staffing: The facility employes 4 staff and 1 Administrator. Staff records are kept confidential. Staff files were reviewed for 1st Aid/CPR, Health Screening with TB results, Finger print/Back ground clearances, Personnel Record/Applications, Reporting Abuse, Criminal Record Statement. At 3:30 PM LPA noted that 2 out of 5 staff were missing original TB results and 1/5 staff was missing original Health Screening. Administrator has misplaced original documents and has made appointments for 2 staff to get a new TB result, 1 staff to get a new health screening and will provide all copies to CCL.

Personnel Records & Training: Staff files and training records were reviewed on this visit. All 5/5 staff had completed required 2023 Annual Training of 20 hours on general requirements, Dementia Care, Restricted Health Conditions, Postural Supports and Hospice Care.

Licensee/Administrator provided LPA will copies of all missing residents forms from last visit.

Exit interview completed, Deficiency cited, copy of report and appeal rights printed/emailed to Licensee.