Facility Evaluation Report

Licensing Program Analysts (LPAs), Alviso and Frank, arrived unannounced to conduct an Annual Required inspection, on 12/16/24 at approximately 11:15am, and met with Tabitha Frampton. LPAs observed another caregiver working at the facility, Erika Nava. Administrator Rose Woodward and Karen Sims, House Manager arrived to meet with the LPAs.

Erika Nava stated they were shadowing/training as they were a new hired staff; Erika stated they had left the facility, back in approximately October 2024, and recently was rehired.

Facility is fire cleared for six (6) non-ambulatory/bedridden residents. Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved dementia plan of operation. Hospice waiver approval is for four (4) residents only.

LPAs toured the facility. Hot water was checked at 116. degrees Fahrenheit, which is within regulation. The fire extinguisher, one (1), was serviced and tagged as required. All smoke alarms were checked, and all worked, but one (1) made a very low toned alarm, the Administrator agreed to follow-up with the fire equipment service that had recently checked/serviced all alarms and the fire extinguisher. All exit doors had auditory alarms on them. All medications were stored appropriately and locked up per regulations. Sufficient supply of linens, paper products, furnishings, hygiene products, and personal protective equipment (PPE) for use by the facility. The facility was at a comfortable temperature. There was sufficient lighting for residents in all common areas, hallways, bathrooms, and resident rooms. The bathrooms had grab bars, and shower mats/non-slip flooring for residents use.

LPAs reviewed six (6) staff files, including training.