Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai and LPA Manuel Monter conducted an unannounced annual inspection focusing on infection control. LPAs met with Administrator Cecilia Eustaquio.

Upon entering the facility, LPAs observed ADM cooking dinner in the kitchen and staff S1 stated S1 was cleaning the bathroom next to the kitchen.

During the tour of the facility with S1, LPAs observed bottles of cleaning solution in entrance to the kitchen, recreation room, 2 bathrooms, 1 living room, kitchen, and outdoor area, where residents were also around. LPAs also observed 2 new cans of insecticides at the doorway entering the kitchen. S1 removed the items in question and locked them away in front of LPAs. S1 acknowledged these items should be locked but did not have a reason why they were kept in common areas, which were easily accessible to residents. Based on review of facility file, facility has been cited in the past regarding failure to ensure poisons were locked and inaccessible to the residents in 2019, 2014 and 2013. Based on resident records and observations, the facility cares for residents who need care and supervision.

LPAs toured the facility to include 4 bathrooms, 6 bedrooms, 2 living rooms, 2 kitchens, recreation room, and exterior. All fire exit routes are free and clear of obstruction. Toxins and sharp objects were secured. Medication stored in a locked room.

Facility observed to have a designated central entry point but did not include a sign-in sheet and temperature check. Facility clean as often as needed. Bathrooms supplied with hygiene products and hand washing signs was observed in 2 out of 4 bathrooms. Trash can with lid was not observed and S1 stated the trash bins will be replaced.