Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was met by Staff Ramoncyruz Odon who contacted Assistant Administrator/Facility Mgr. of Operations Fritzie Cube and arrived at facility shortly after. There are 4 clients at the facility..

LPAs arrived at the facility and had her temperature checked and logged. All staff are temperature checked and logged each shift and wear masks. During facility tour on 8/24/2021 with Asst. Admin. Fritzie Cube, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 09/17/2020 at the time of the visit. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked closet in the laundry room & under kitchen sink. Medications are stored locked and inaccessible to clients in locked med cart next to kitchen. Clients files are kept in locked closet next to med cart and staff records are kept in locked office. There was a supply of cleaners, hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Hot water temperature measured between 115.3 degrees F & 116 degrees F which is within acceptable regulations of 105 to 120 degrees F in client’s bathroom faucets. Facility has outings for clients to parks, and other activities during the day such as gardening and arts & crafts.

Staff 1 has required 1st Aid and CPR certificates, with expiration date of 01/03/2022, S2 has requirements through 03/10/2023, S3 has requirements through 05/2023, & S4 has requirements through 05/2022.

Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in kitchen, laundry room & garage. Facility has a 30-day supply of medication for clients. Clients are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Asst. Administrator stated all staff are required to be vaccinated prior to hiring and are being tested weekly.