Facility Evaluation Report

Licensing Program Analysts (LPAs) Alviso and Contreras arrived to conduct a case management inspection, on 3/3/25 at approximately 9:35am, and met with LPT Judy Columbo.and Administrator Susan Webster. This inspection is being conducted to review operations of the facility to ensure compliance with regulations. Facility is on a compliance plan with the Department, effective 3/21/18, for a period of 2 years.

LPAs toured the facility with the Administrator. Hot water was 114.6 degrees Fahrenheit. Fire extinguishers were serviced and charged as required. Food supply was sufficient. Medications were centrally stored and locked up making them inaccessible to residents in care. Cleaners/disinfectants were locked up and inaccessible to residents in care. Facility had the 72 hour shelter in place required supplies. Sufficient supply of paper products, cleaners, linens, and personal protective equipment (PPE). LPAs toured the resident rooms, bathrooms, and common areas.

LPAs reviewed staff files, including training. All staff had criminal record clearance as required.

The following deficiencies were observed during the inspection:

LPAs observed a big lock hanging on the fire exit gate upon arrival; LPAs obtained photos, and discussed fire clearance approval and the observed fire clearance violation with the Administrator. Administrator stated the lock will no longer be used . LPAs obtained photos. This deficiency will be cited, 80020(a) Fire Clearance- All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal, see LIC809D. Civil penalty assessed in the amount of $500, see LIC421IM.

Per file reviews and interviews with Administrator, there was no proof of staff having had required training on the facility's emergency disaster plan. Administrator was not able to provide the staff training to the LPAs, This deficiency will be cited, HSC 1569.695(b) Emergency Disaster Plan- A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster, see LIC809D.