Facility Evaluation Report

08/19/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. There are currently 3 residents in care. Facility approved/cleared for three non-ambulatory. Hospice waiver approved for two.

LPA and Licensee toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

All rooms were furnished per regulation. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 118.2 which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected July 2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins and sharps were located in the a designated closet and found to be secured. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Facility conducts quarterly fire/disaster drills with the last one being conducted April 2025.

LPA conducted a review of 3 resident records. LPA observed 3 out of 3 resident files to have missing needs and service plan, per conversation with licensee, they will get a need and service plan for all residents. LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.