Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Prince-Stanley Amas.

During visit, LPA toured the facility inside and out. LPA toured the facility kitchen and dinning area. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The first aid kit was reviewed and found to be complete.

LPA toured 12 out of 12 bedrooms in the 68 South 10th Street building and 20 out of 20 bedrooms in the 64 South 10th Street building. Each bedroom had working lights and available bedding and clothing storage areas. LPA Marrufo toured 3 out of 3 resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 118 F, 108 F, and 111 F. LPA toured the outside area and found the exits to be clear of obstructions. The smoke detector system was tested during visit and found to function properly when tested. LPA tested 2 out of 2 carbon monoxide detectors and found them to function properly when tested.

LPA reviewed the Centrally Stored Medication and Destruction Records (CSMDRs) and resident records for 5 residents. All 5 reviewed CSMDRs were found to be complete. Resident R1 was missing a Consent Form, Safeguard for Property and Valuables form, and LIC613 Resident Rights form. R2 was missing a Consent Form, Appraisal/Needs and Services Plan, Safeguard for Property and Valuables form, and LIC613 Resident Rights form. The other 3 reviewed resident records were found to be complete. 1 out of 1 resident Personal and Incidental Money Log was reviewed and found to be balanced. LPA reviewed 5 staff records and found them to be complete.

A deficiency was cited as per California Code of Regulations Title 22. This report was reviewed with ADM Prince-Stanley Amas and a copy of this report and appeal rights were provided.