Facility Evaluation Report

On 12/15/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member (SM), Arsenia Villadarez and explained the purpose of the visit. It was asked at this time that SM Villadarez call the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. LPA was able to speak to FDA Karin Lastimosa via telephone and it was learned that they were unable to come to the facility at this time due to other obligations. LPA was able to continue the visit with SM Villadarez.

Current census was 2. 1 out 2 residents were out at their respective day program at this time.

This facility is licensed to serve residents who are 60 and older. All 6 residents may be non-ambulatory. This facility also has a hospice waiver on file.

LPA reviewed 2 resident files. It was observed that 2 out 2 residents did not have an updated physicians report and did not have a Needs and Appraisals Plan on file. LPA reviewed 3 staff files. It was observed that 1 out 3 staff files did not have an active First Aid Certificate at this time. The current administrator has a

current administrator certificate #6018146740 and expires until 07/07/2024.

A tour of the facility was conducted. Fire extinguisher was observed to be annual inspected on 11/14/2023 by Arrow Fire Protection Company. Smoke detectors and carbon monoxide was in good repair.

A tour of the kitchen was conducted. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable food supply at this time. LPA observed a washer and dryer in the kitchen. Laundry soap was accessible at this time. LPA observed dish soap and toxins under the sink and was not locked and made inaccessible. LPA also observed a large part of the counter chipped off near the dishwasher. A medication cabinet was observed in the kitchen. Along with SM Villadarez, medication and medication dispensing logs were reviewed and compared. First aid kit was present and contained all the required components.

A tour of 3 resident bedrooms were conducted. Furniture and other furnishings were observed to be in good repair at this time.

A tour of 2 resident restrooms were conducted. LPA observed that one resident restroom did not have knob and observed water damage near the grab bar in the bathtub. It was stated that no residents use the tub at this time. Hot water temperature was taken to ensure it was within Title 22 regulations at this time.