Facility Evaluation Report

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

During visit, LPA toured the facility inside and out. The facility kitchen area and food storage areas had a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The cleaning supplies and knives were kept in the locked kitchen area.

LPA toured the facility and tested the carbon monoxide detector and the smoke detectors in each resident room, hallways, and living room areas. Each smoke detector and the carbon monoxide detector functioned properly when tested.

LPA toured the outside area and found it to be clear of obstructions. Two out of two bathrooms were toured and each bathroom had working lights and available soap and paper towels. The bathroom sink water temperatures were 119 F and 114 F.

LPA reviewed the Personal and Incidental Money Logs for 3 out of 3 residents for whom the facility safeguards money. 3 out of 3 Personal and Incidental Money Logs were balanced during review. LPA Marrufo reviewed the Centrally Stored Medication and Destruction Record (CSMDR) for 5 out of 5 residents and each CSMDR was complete. LPA Marrufo reviewed resident records for residents R1-R5 and each reviewed resident record was missing a Safeguard for Property and Valuables Form. Resident R1 only had the first page of the LIC602 Physician's Report. LPA reviewed staff records for staff S1-S5. Staff S1 and S4 were missing current first aid certifications. Staff S1 was missing an LIC501 Personnel Record. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D page for more information. An Advisory Notes were issued. See LIC9102s for more information. This report was reviewed with ADM Ariel Palencia and a copy of this report and appeal rights were provided.