Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Interim Executive Director Karen Moore, Tolu Faaita Business Office Mgr., and Guadalupe Villa-Guerrerro Director of Health Services. There are 43 residents present at the facility with 8 on Hospice. Facility has activities planned for residents during the day.

LPA arrived at the facility and had her temperature checked and logged into electronic system. During facility tour on 3/16/2022 with Business Office Manager; 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 12/7/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked inside housekeeping closed on the hallway. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Hot water temperature measured between 111.7 degrees F and 114.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 7 of 7 resident’s bathroom faucets. Residents’ medications are stored and locked in the medication cabinet at med room. Facility has a 30-day supply of medication for residents.

Facility has submitted a mitigation program plan that was approved on 5/14/2021. Posters have been placed at entrance, and facility has a station at main entrance with AccuteShield kiosk, hand sanitizer and other items designated for visitors and staff. Staff before coming into work have temperature checked.