Facility Evaluation Report

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection visit of the facility. LPA was welcomed by Licensee/Administrator, Ladana Luellen. There is a total of 5 residents in care, 2 currently on Hospice, 1 with dementia.

LPA toured the facility on 2/20/2024 at 8:45 AM with staff Arthur “Lee” Luellen; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices; (although they were not turned on during today’s visit (see LIC809-D). Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Fire extinguishers were last checked 10/13/2023. Hot water temperature measured between 114.9 degrees F and 118.5 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food 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 cabinet in the laundry room. Dangerous items were found stored inaccessible to residents with dementia. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Medications were centrally stored in locked cabinet in facility office/kitchen.

A review of five resident & two staff records as well as medication audit was conducted. LPA reviewed resident’s files at 10:00 AM on 2/20/2024 and learned that 1 of 5 residents (R1) do not have an appraisal or updated re-appraisals/needs & care plan (see LIC809-D) and 5 out of 5 residents physician’s assessments (LIC 602A) are updated as required by Title 22 Regulations on file.