Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to continue the annual inspection from 5/2/2024. LPA Rai met with Lead Staff (LS) Mary Ann Villanueva. LPA Rai observed 2 staff and 6 residents at the facility. At this time, the facility has 2 hospice residents.

During today's visit, LPA Rai followed up with 2 staff files. On 5/2/2024, LPA Rai reviewed 1 staff file for S1 where first aid training was expired. During today's visit, LPA Rai observed S1's first aid training was completed on 5/3/2024. On 5/2/2024, LPA Rai reviewed staff file for S2 where S2's Tuberculosis (TB) test was not included in the health screening and a separate TB test results were not found in the file. During today's visit, LPA Rai observed S2's TB test result in the file with a note stating the new records were from another facility the Licensee currently manages along with this current facility.

During today's visit, LPA Rai reviewed 2 resident files who are not on hospice services. LPA Rai observed R1-R2''s file did not contain the Appraisal/Needs and Services Plan. R2's file did not contain a signed order for half-side rails attached to R2's bed and LS clarified R2 is not on hospice services. R2's file did contain an Admission Agreement but it's not for this current facility.

LPA Rai observed the water temperature in the bathroom sinks ranged from 118.4 degrees Fahrenheit - 119.3 degrees Fahrenheit. The water temperature in the kitchen sink was 118.9 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 4/5/2024. LPA Rai observe the thermometer in the freezer was measured at 0 degrees Fahrenheit and the thermometer in the fridge was measured at 40 degrees Fahrenheit.