Facility Evaluation Report

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

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area and the food storage areas. LPA Marrufo observed a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a first aid kit and found it to be complete.

LPA Marrufo toured 12 out of 12 resident bedrooms and observed each bedroom to have available bedding and clothing storage areas as well as functioning lighting. During visit, Administrator Cyril Inneh tested the central smoke and carbon monoxide detection system and the system functioned properly when tested.

LPA Marrufo toured two out of two resident bathrooms and observed there to be functioning lights and available soap and paper towels. The bathroom water temperatures measured at 116 F.

LPA Marrufo toured the outdoor exits and found them to be clear of obstructions.

LPA Marrufo reviewed 5 resident records. 5 out of 5 reviewed resident records had complete and balanced Personal and Incidental Money Logs. During visit, Centrally Stored Medication Logs were not available to be reviewed because the records were kept on a damaged computer and had not been printed. Resident R1's records were missing the Safeguard for Property/Valuables form, Consent Form, Personal Rights Form, and R1's Appraisal/Needs and Services Plan was missing signatures. R2 was also missing a Personal Rights form. During review of records for staff S1-S5, staff S1, S4, and S5 were missing current 1st aid certifications, S1 and S3 were missing Health Screening forms, and S3, S4, and S5 were missing Employee Rights forms. See LIC809-C for more information. Page 1 of 2.