Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a Required -1 Year inspection, on 1/23/25 at approximately 9:20am, and met with Sarah Araya, Administrator. LPA observed two caregivers on duty during the inspection. Currently there are four (4) clients in care.

The facility has a fire clearance for six (6) non-ambulatory residents. Facility has a required infection control plan, and a required emergency disaster plan. Hospice waiver approval is for two (2) residents. Per record review, facility is holding quarterly emergency disaster drills as required. Fire extinguisher was serviced and tagged as required.

LPA reviewed four (4) resident files. Medications, and medication records were reviewed.

LPA reviewed four (4) staff files, including training.

LPA toured the facility with the Administrator. Hot water was checked at 110.4 degrees Fahrenheit, which is within regulation. LPA observed sufficient food supply. LPA observed sufficient supply of paper products, cleaners/disinfectants, hygiene products, and personal protective equipment (PPE). Facility had sufficient lighting in resident rooms, common areas, bathrooms, and hallways for resident use.

Bathrooms had required grab bars, and non-slip flooring/mats in showers/bathtubs for resident use. Medications are stored in a closet that is locked, making medications inaccessible to residents in care. Cleaners/disinfectants are kept locked and inaccessible to residents in care.

LPA discussed regulation regarding fire clearance and ensuring all fire exits are fully cleared/unobstructed at all times as required. Administrator stated their understanding. Administrator had staff move the table from blocking part of the slider door exit during the inspection.