Facility Evaluation Report

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 12:50 pm was greeted by Interim Administrator, Enedelia Avila. Also present during the inspection was Jennifer Farley, Program Director, and Leticia Villareal, Quality Management Manager. At the time of arrival, there were 15 residents in care and 5 staff on duty.

A Mitigation Plan has been submitted to CCLD. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis and a hospice waiver for two residents. Currently there are no residents on hospice.

The facility has an entry station at the front of the building. Upon entry, staff, visitors, and residents returning from an outing are required to sign-in, complete a symptom questionnaire, and have a temperature screening. All documentation is kept in a binder filed on a weekly basis. The entry station has PPE gear, hand sanitizer, and disinfecting wipes along with a thermometer.

A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete.

The facility has a dining area and common area for activities, a computer room located off the hallway, a exercise room, and an enclosed patio for gardening and visitation. Cleaning supplies are kept in a locked custodian closet.

The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There are approximately seventeen (17) fire extinguishers on the premises last serviced on 4/20/2022 and 4/21/2022. There are seven (7) fire pull alarms that will alert the l