Facility Evaluation Report

Licensing Program Analyst (LPA) Walters arrived unannounced to conduct a 1-year required annual inspection and was greeted by Staff, Charity Buttler. The Administrator was not available for today's visit. The Licensee, Mantu Sandhu arrived later. The facility has submitted a mitigation plan which was approved by Community Care Licensing on 07/06/21. This visit will focus on the infection control of this facility.

Upon entry there were two sign-in binders, with a temperature gun for visitors and home health providers. Staff sign-in on binders at a separate entrance. All staff were wearing mask. LPA continued to tour the facility with staff and made the following observations. 1 of 4 bathrooms was not supplied with hand washing supplies. LPA also observed that the shower head had been removed and was laying on the floor. (pictures taken). Non-Slip mats used by resident were discolored and had mold on it. (pictures taken) In the third bathroom, the hand railing had fallen out. (pictures taken) Resident's bedroom had all necessary items as required per regulation. LPA observed that bedroom 6's door knob was taken off. Per interviews with staff the knob was taken off prior to the resident moving into the bedroom an was never placed back on. In the entertainment room, a floor board had lifted. LPA informed Licensee of the safety issue. Licensee agreed to repair.