Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Administrator (ADM) Zosima Rillera.

During visit, LPA Marrufo toured the inside and outside of the facility. During visit, LPA toured the kitchen 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. LPA observed the first aid kit and found it to be complete.

LPA toured four out of four bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke/carbon monoxide detectors in the hallways and resident rooms and found them to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. LPA measured the water temperatures in both bathroom sinks and they measured at 109 F.

LPA toured the outside area and found both exits to be clear of obstructions.

LPA reviewed five out of five resident records. Resident R1 had three medications missing in his/her Centrally Stored Medication and Destruction Records. The rest of the resident records were complete. LPA reviewed five staff records and found them to be complete.

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