Facility Evaluation Report

Licensing Program Analyst (LPA) Erika Miller arrived at 10:36 a.m. to conduct a 1-year required annual visit. LPA met with Joanna Enriquez, Administrator. 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 a current Infection Control Plan. 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 10 resident rooms and observed that rooms were tidy, the lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and locked in kitchen closet. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use. The fire extinguishers were last charged and inspected on 10/20/23. The facility has carbon monoxide detectors and a sprinkler system that were tested 10/3/24 and 5/31/24 respectively.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 140. The fire clearance is granted for 140 non-ambulatory of which 10 may be bedridden. Hospice waiver approved for 40 residents. The facility currently has 46 non-ambulatory, and 1 bedridden resident. There are currently 3 residents on hospice..