Facility Evaluation Report

Licensing Program Analyst (LPA) Marcela Yanez and Christine Dolores conducted an unannounced Required 1 Year visit and met with Daisy Estoesta, Administrator/Licensee.

During visit, LPAs toured the facility inside and out with staff . LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and refrigerator temperature measured with thermometer at 39.5 degrees F and freezer measured with thermometer at 0 degrees F.

LPAs observed locked cabinets for medications, sharp objects, and cleaning supplies. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days.

LPA toured four resident bedrooms. Each resident bedroom had available bedding and clothing storage areas as well as functioning lights. LPAs observed full length bed rail in bedroom #3 picture was taken of full length using LPA Yanez state provided phone. LPAs reviewed resident record and no doctor order was found for the full length bed rails. The review of residents IPP and Needs and Services Plan did not indicate the need for full length bed rails. Administrator stated the full length bed rails is for behavior to help resident fall asleep.

Administrator tested the smoke detectors in the hallway and found the smoke detector to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 123.4 degrees F in bathroom #1 and 124.8 degrees F in bathroom #2. Administrator was advised of Ttle 22 regulation that the water temperature shall be maintained between 105 degrees F and not more then 120 degrees F.