Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct an Annual Required - 1 Year inspection, and met with Administrator Megan Leone.

Fire clearance is approved for one hundred and seventy-three non-ambulatory, of which 16 may be bedridden. The delayed egress is approved, per fire clearance. Capacity breakdown as follows: AL main building, and the five (5) bungalows are cleared for one hundred and forty (140) non-ambulatory, of which six (6) may be bedridden, the MC building is cleared for thirty-three (33) non-ambulatory, of which ten (10) may be bedridden; Total license capacity is one hundred and seventy-three (173).

Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has a plan of operation for dementia care. The facility has a hospice waiver approval for ten (10) residents.

Per review of the emergency disaster drills binder, the facility is conducting emergency disaster drills.

All exits were clear and unobstructed during the inspection.

Facility was observed to be at a comfortable temperature. There was sufficient lighting in the entryway and hallways that the LPA observed during the inspection.

LPA reviewed ten (10) resident files, including medication records.

LPA reviewed ten (10) staff files. All staff had required criminal record clearance. Staff reviewed, had the required first aid certification and CPR certification. LPA reviewed required staff training, for all direct caregivers and medication technicians.

This annual inspection will be completed at a later date by the Licensing Program Analyst (LPA).