Facility Evaluation Report

Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Staff (S1) Josie Fernandez and explained the purpose of the visit. LPA subsequently met with Quality Management Manager (QMM) Leticia Villarreal and explained the purpose of the visit.

LPA was screened at the administration office prior to entering the facility. Program Director Jennifer Farley approved S1 to tour the facility with LPA and sign report. At 11:40 a.m., LPA entered the medication room as the top portion of the dutch door was open. LPA then opened an unlocked drawer containing routine and PRN medication for a client. Staff was not present when LPA entered the medication room. LPA informed S1 that centrally stored medication needed to be locked and accessible only to employees responsible to centrally stored medication. S1 locked the cabinet and dutch door. LPA issued citation on 809D. At 11:50 a.m., LPA observed the wall across the medication room having paint chips falling off and was able to view the intersections of the plywood. LPA issued a technical advisory. LPA observed several window screens that were not in good conditions as one had a hole the size of a golf ball, few others had dents, and one had grass debris. LPA issued technical advisory. LPA discussed items in the Infection Control Module and noted that the facility had handwashing signs in one of two the bathrooms. The facility did not have Covid signage posted throughout the facility but all signs were posted outside the facility or on the window of the medication room. QMM had staff post signs throughout facility prior to LPA's departure. Infection Control module was addressed with QMM to satisfaction.

LPA conducted exit interview with QMM and emailed a copy of today's report and appeal rights to the QMM.