Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Cecilia Eustaquio.

During visit, LPA Marrufo toured the facility inside and out. The kitchen area had locked storage areas for sharps, cleaning supplies, and medications. There was a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days.

2 out of 2 resident bathrooms were toured. One bathroom had water temperature at 125 F and the other had water temperature at 130 F.

LPA toured 6 out of 6 resident bedrooms. The resident bedrooms had working lights and available bedding and clothing storage. 4 rooms had malfunctioning smoke detectors, but the facility staff replaced them during visit. The facility staff installed 1 carbon monoxide detector in each of the 2 facility buildings during visit.

The Centrally Stored Medication Logs (CSMLs) were reviewed for 8 residents. 5 out of the 8 CSMLs had medications that were not recorded. All 8 CSMLs did not have start dates for any medications. Resident and staff records were reviewed. Resident R1 was missing an Admission Agreement, Safeguard of Property and Valuables, Consent Forms, Emergency Contact and Information Form, and LIC613 Personal Rights. R2 was missing Safeguard for Property and Valuables. R4 was missing an Admission Agreement, Physician's Report, and Safeguard for Property and Valuables. R5 was missing Consent Form, Safeguard for Property and Valuables, and LIC613 Personal Rights.

Staff S1 was missing LIC508 Criminal Record Statement and LIC9052 Emplo yee Rights. S2 was missing LIC9052 Employee Rights. S3 was missing LIC9052 Employee Rights and Current 1st Aid Certificate.

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