Facility Evaluation Report

Licensing Program Analysts (LPAs), Alviso and Loera, arrived unannounced to conduct a Required-1 Year Inspection. Stationed at the front entrance of the facility there is a security guard who screens visitors upon entry; LPAs were provided a parking pass and allowed entry onto the grounds.

LPAs met with Administrator Bill Keck, Skilled Nursing Administrator Dan Skillman (back-up RCFE Administrator), and Director of Resident Health Services (RHS), Sharon Shnell-Hobbs.

Fire clearance is approved for six hundred and seventy-nine (679) may be non-ambulatory, of which two (2) may be bedridden. Hospice waiver approved for forty (40) residents. Approved delayed egress in memory care unit. Facility has a required emergency disaster plan. Facility has a required infection control plan. Last evacuation drill was held on 6/7/24, and last fire drill was 6/7/24, per review of records. LPA discussed the emergency plan regarding emergency drills, these are to be conducted quarterly per H&S Code.

LPAs reviewed five (5) resident files. All were complete. LPAs reviewed five (5) staff files. Staff had criminal record clearance as required. Staff had first aid and CPR certification as required. Staff had required training.

LPAs toured the facility grounds with RHS Sharon, memory care unit, and assisted living units.pendent units. Hot water was checked at 119.1 degrees Fahrenheit. All exits were observed to be clear of obstruction. Fire extinguishers were tagged and serviced- dated 1/9/2024. LPAs observed a sufficient supply of food. Medications were centrally stored as required, including refrigerated medications. Medications are kept in medication carts, including double locked narcotic medications. All exits doors, walkways, and breezeways had sufficient room for residents to ambulate and were found to be clear.

LPA is requesting the following documents be updated and submitted by 9/16/24.

LIC308 - Designation of Administrator Responsibility

LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working

LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)