Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting an Annual required inspection and met with Maureen Bleck Nursing Supervisor. Administrator Sarah Lucas was not able to come to the facility, but was available by phone and gave authorization for staff to sign the report. There are currently 4 clients in care.

LPA initiated tour of the facility at 11:00am: The facility was a comfortable temperature, free from obstructions. and was well lit. Extra hygiene products and linens were available. Water temperature in resident's bathrooms measured at 109.3 and 112.3 degrees F which is within acceptable range of 105 to 120 degrees F. Cleaning products will be located in a locked cabinet in the garage. Perishable and non-perishable foods were found to be stored in a safe manner and met the required minimum with a 7 day supply of non-perishable foods and 2 day supply perishable foods. 3 of 4 clients are currently on liquid diets via G-Tubes. All areas are able to accommodate wheel chair access. Facility has fire sprinklers throughout which was tested by Santa Rosa Fire Equipment January 2023. Fire Detectors are hardwired and facility has a fire pull station which activates sound and light devices on the ceiling. Fire extinguisher inspected was charged October 2023. Carbon Monoxide detector was located in the hallway. Facility does have a portable generator in the event power is disrupted. Facility have a nurse (2 LVNs) 8 hours a day to oversee medical needs and medication. An RN is available on-call at all times. Medications are stored in a locking medication cart located off the living room. Medications and medication records were reviewed. LPA observed van to be used for transportation. Facility maintains a maintenance binder for review. P&I monies is documented, secure and not commingled.

At approximate 11:15am Per Administrator, the last disaster drill was conducted on April 2023.