Facility Evaluation Report

01/16/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 3 clients in care. Facility is currently in the process of remodeling the master bedroom and bathroom. Per conversation with Administrator, construction started 01/09/2025 and should be done by Sunday (01/19/2025).

At approximately 12:50pm, LPA and Administrator 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.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 109.9 and 117.4 which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 10/2024. Facility conducts fire drills with the last one being conducted 01/2025. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired. Sharps are kept in a locked drawer located in the kitchen. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of 3 client records. 2 of 3 records had the required documentation. One client was missing their medical assessment/TB. Per conversation with Administrator Client 1 (C1) got a hold of their binder and ripped up paperwork. Administrator notified LPA, C1 has a doctors appointment later today (01/16/2025) and will be receiving an updated medical assessment/TB and needs and service plan. 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. However, Staff 1 (S1) was missing their medical assessment/tb. Per conversation with Administrator S1 has had their physical done and will get a copy to put in their file.