Facility Evaluation Report

Licensing Program Analysts (LPAs) Marcella Tarin and David Marrufo conducted a required 1 year inspection. LPAs met with Caregiver, Emilio Hofilena due to Administrator being out sick. LPAs toured the facility inside and out.

LPAs toured the kitchen. LPAs observed a 7 day supply of nonperishable food and a 2 day supply of perishable food supply. LPAs observed the refrigerator temperature at 37 degrees F and the freezer at 0 degrees F. LPAs tested 5 smoke detectors in the living and 4 out of 4 resident bedrooms. LPAs observed smoke detectors to be functioning properly. LPAs toured 2 resident bathrooms and the water temperature was recorded at 107 degrees F. 2 out of 2 resident bathrooms had soap, paper towels and functioning lights. LPAs toured 4 resident bedrooms. 4 out of 4 resident bedrooms had functioning lights, and storage space for resident belongings.

LPAs reviewed 3 Centrally Stored Medication and Destruction Records (CSMDR). 2 out of 3 CSMDRs were reviewed as complete. Resident 2 (R2) and Resident 3 (R3) CSMDRs were reviewed as complete. Resident 1 (R1) was missing 3 medications on the CSMDR.

LPAs reviewed 3 out of 3 Personal and Incidental Money (PNI) logs. 3 out of 3 PNI logs were complete. LPAs reviewed 3 resident records. R1-R3 resident records were missing consent forms. R2 and R3 resident records were missing LIC613C (Personal Rights).

LPAs reviewed 4 staff records. 1 out of 4 staff records were reviewed as complete. Staff 1 (S1)'s record was complete. S2-S4 staff records did not contain employee rights LIC9052.

See LIC809-C for more information. Page 1 of 2.