Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management for annual continuation from 1/23/2025. LPA Rai met with Administrator, Elizabeth Bautista and stated the purpose of today's visit.

The hot water temperature in the bathroom sink ranged from 105.1 - 105.3 degrees F.

Fire extinguisher was observed and inspected on 1/24/2025. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills were conducted on 1/7/2025 and 1/9/2025.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai observed resident R2 with a full bed rail. ADM stated R2 was not receiving Hospice care at this time. LPA Rai reviewed R2's facility file and R2 did not have a written physician's order for full bed rail or half bed rail. ADM stated she will work with R2's physician to obtain a written physician's order for half bed rail and remove the full bed rail from R2's bed.

LPA Rai observed R3, R4, and R5 with half bed rails who are not receiving Hospice care at this time. LPA Rai reviewed R3, R4 & R5's facility file and they did not have a written order from physician for using a half-bed rail for mobility use. ADM stated she will work with the resident's physician's to obtain a written physician's order for half-bed rails.

LPA Rai reviewed R5's facility file and reviewed a medical assessment conducted on 6/13/2023 and ADM stated R5 was not recently seen by physician. ADM will work with R5's responsible party and physician for R5 to receive an annual routine visit with physician.