Facility Evaluation Report

09/03/2024, Licensing Program Analysts (LPA) Loera and Alviso conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility is an enhanced behavioral. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently four(4) residents in care. Facility approved for four(4) non-ambulatory.

At approximately 9:30am, LPAs 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 being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. LPAs observed a clients room with broken/missing blinds (Deficiency Cited) . Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 113.2 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected May, 2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients in care were found to be locked and secured in a cabinet located in the kitchen.

At approximately 10:45 am, LPAs conducted a review of four(4) client records. All records had the required documentation. P&I monies were documented, secure and not commingled.

At approximately 11:15 am, LPAs conducted review of four(4) 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.