Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct a Required -1 Year inspection, on 8/15/23 at approximately 11:05am, and met with Sandra Ambrecht, lead caregiver. Licensee/Administrator Pamela Johnson was notified of LPA's arrival.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. The facility has a required infection control plan. The facility has a required emergency disaster plan. Fire clearance is approved for six (6) non-ambulatory. There are currently six(6) residents in care; One(1) resident is on hospice services.

The LPA reviewed six(6) resident files. All files were complete.

The LPA reviewed three(3) staff files. All staff have required criminal record clearance. All staff have current First Aid and CPR as required. All staff have training as required.

The LPA toured the facility with caregiver Sam. Hot water was checked at 107.9F. All exits were clear and unobstructed. The bathrooms all have grab bars as needed. Showers have mats/non-slip flooring for resident use. Facility has sufficient furnishings for resident use. Facility has sufficient lighting throughout the facility, in resident rooms, bathrooms, and common areas. LPA observed a sufficient supply of food, perishable and nonperishable. Facility had all toxins/disinfectants locked up and inaccessible to residents in care. All medications were locked up and inaccessible to residents in care.