Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a continuation of the annual inspection from 1/9/2024 and met with Interim Executive Director, Brenda Ritter. LPA Rai continued the annual inspection with Angel Bustos, Resident Service Director and Patty Cuzia (RDH) Regional Director of Health Services.

LPA Rai toured the kitchen and dining room. LPA Rai observed 2 days of perishable food supply and 7 days of non-perishable food supply. LPA Rai observed a delivery of water gallons during visit and facility had water supply in the pantry, emergency supply closet and kitchen. LPA Rai observed daily temperature log of refrigerator and freezer.

During visit, LPA Rai continued to review 5 resident files. LPA Rai observed 5 out of 5 resident files not including weight log. Resident Services Director (RSD) Angel Bustos stated the resident files do not have weight log and the staff are not monitoring Assisting Living resident's weight at this time. RSD stated the facility did order and received a weight machine which will accommodate a wheelchair therefore the facility will initiate weight log for Assisted Living residents.

RSD stated the facility recently took over as managing group from the previous managing group and the current facility will honor all Admission Agreements signed by residents and resident's families from the previous managing group. RDH stated the new residents signing under the facility will have new admission agreements reflecting the name of the facility.

During a random review/audit of Assisted Living resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record. LPA Rai along with RSD and Resident Care Coordinator (RCC) counted the tablets from the medication bottles, 4 out of 4 medications prescribed to R1 was given as prescribed by the doctor, but the medication count was not correct.