Facility Evaluation Report

Licensing Program Analysts (LPAs), Alviso and Contreras, conducted a Required- 1 Year visit, on 4/1/25 at approximately, and met with Administrator/Licensee Catherine (Cathy) Clark. Currently there are four (4) residents in care.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. Facility has a required infection control plan. Facility has a required emergency disaster plan. Fire clearance is approved for five (5) non-ambulatory, which includes two (2) bedridden in room #3 only.

LPAs reviewed four (4) resident files. All files were complete.

LPAs reviewed three (3) staff files. One staff, S2, was not associated as required. S2 lacked first aid certification as required; These deficiencies are cited, see LIC809D. S2 not being associated is an immediate civil penalty, assessed in the amount of $100, see LIC421BG.

LPA's toured the facility with the Administrator. Hot water was measured at 118. degrees Fahrenheit. All exits were clear and free of obstruction. All exits had auditory alarms. All postings were up and visible to all entering the home. Facility had sufficient food supply. Facility had sufficient supply of cleaners, paper products, and personal protective equipment (PPE). All bathrooms had grab bars, and shower mats for resident use. Medications were locked and inaccessible to residents in care.

LPA are requesting the following documents be updated and submitted to CCL by 6/23/2025:

LIC308 - Designation of Administrator Responsibility