Facility Evaluation Report

Licensing Program Analyst(LPA) Alviso conducted an annual inspection, on 2/13/25 at approximately 1:40pm, and met with Tamra Richmond, Business Office Manager. Jose Acumabig, Administrator was not on-site today and available to meet with the LPA.

The facility has a required infection control plan. Hospice waiver is approved for ten (10) residents only. The facility has a required emergency and disaster plan. Facility is fire cleared for seventy-five (75) non-ambulatory residents. Fire cleared resident rooms/units are 157-187 on the first floor, and 257-287 on the second floor.

LPA reviewed six (6) resident files. All files were complete.

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

Per record reviews, last fire drill was 1/29/25 and last elopement drill was on 9/25/24.

LPA met with the Activity Director Shaianne Chantavong, and reviewed the facility's activity calendars; Per review of records, activities are being conducted with assisted living residents as required.

LPA observed that all stairwells of the facility had evacuation chairs, to be used as needed for residents in an emergency. There was a sufficient supply of food, perishable and non-perishable. The medications were locked up and stored appropriately as required. Medication narcotics were double locked and counted on each shift. PRN and medication records were found to be accurate, and maintained as required. There was a sufficient supply of personal protective equipment (PPE) to use as needed. Sufficient supply of disinfectants/cleaners, and paper products. All cleaners/disinfectants were locked up and inaccessible as required. Sufficient furnishings for residents use. All hallways throughout the facility had sufficient lighting for residents in care. Fire extinguishers were serviced and tagged as required. All exits were free and clear of obstruction. The facility was at a comfortable temperature for residents in care. LPA observed residents engaged in a facility activity during the inspection.