Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso conducted a case management annual continuation inspection, on 4/9/25 at approximately 9:45am, and met with caregivers Jordan and Lorena, both Lead staff. The annual was opened and started on 4/1/2025, see report LIC809.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for three(3)residents. Facility has a required infection control plan. Facility has a required emergency and disaster plan. Facility does have a generator for emergencies if needed. The facility does have emergency food, water, and supplies to meet the "72 hour shelter in place" requirements.

LPA reviewed fire drills and emergency disaster drills, and these are conducted as required. Fire extinguishers are serviced and tagged. Facility has working smoke alarms and carbon monoxide detectors.

LPA reviewed six (6) resident files. Files were complete. LPA discussed the updated/changes in regulations with the lead staff Lorena. LPA emailed the Departments PIN ASC- #24-09, regarding the regulation updates, to the Licensee/Administrator.

LPA reviewed five (5) staff files. LPA reviewed staff training. All staff have first aid certification and CPR certification as required.

No deficiencies cited during today's inspection.

LPA conducted an exit interview by phone with Administrator Mera Shaughnessey. Exit interview conducted with Lead taff Lorena Madrigal. Report LIC809 left for the Administrator.