Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Caregiver, Rosa Ascencio. Licensee, Leah Archer was available by phone and gave permission for caregiver to sign report. Required postings were observed. Contact information was reviewed.

LPA/staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 114.7 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required grab bars. Kitchen cabinet containing cleaning supplies was locked. Medications were centrally stored and locked. Fire extinguisher charged and serviced as of February 2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have auditory alerts that were functional at time of visit. Last disaster drill was conducted on February 2024. Facility has at least two days of perishable and one week of non-perishable foods. At approximate 9:15am LPA/staff observed one can of dark red kidney beans expired as of May 2023, one can of mixed vegetables expired as of 1/21/2024 and a classic yellow mustard expired as of 5/1/2021.

File review was initiated at 9:30 am. Three staff files and five resident files were reviewed. One out of five residents (R1) care plan needs to be updated a technical violation was issued. Also, LPA had a discussion with Licensee via phone about medical assessments and mild cognitive diagnosis because some residents have not been evaluated for a couple years. Licensee agreed to have resident re-assessed by their physician to confirm that they have the same diagnosis, and technical advisory was issued. Staff have required First Aid and CPR certificates. However, one out of three staff (S1) file is missing, but LPA confirmed that S1 has been associated and cleared in Guardian website as of 3/14/24. Licensee confirmed to LPA that S1 just started a week ago, and ensured to LPA that they are only shadowing staff. LPA explained to Licensee that S1 needs to have required documentation on file. Administrator's certificate for Leah Archer 6033354740 expires 12/23/2024. Continued on LIC809C...