Facility Evaluation Report

Licensing Program Analyst (LPA) Erika Miller arrived at 10:30 a.m. to conduct a 1-year required annual visit. LPA met with Dorothy Queja, Administrator and Licensee. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Infection Control: The facility has at least a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE).

Physical Plant & Environment Safety: LPA was authorized to enter and inspect facility. LPA toured resident rooms and observed that rooms were tidy, free of odor, the lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational.The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. The fire extinguisher was last charged and inspected on 7/13/23. Administrator agreed to have extinguisher inspected immediately. The facility has carbon monoxide and smoke detectors that were tested and working.

Operational Requirements: The facility has a current plan of operation on file with the department and has current liability insurance that expires on 6/1/25. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-ambulatory residents. The facility has a hospice waiver for 2. (Continued on 809-C)