Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 11/14/24 at approximately 1:35pm, and was greeted by caregiver Isabel. There are currently six (6) residents in care; Currently there are two (2) residents on hospice care. Administrator arrived to meet with the LPA.

There is an approved hospice waiver for three (3) residents. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. Facility has an approved dementia plan of operation.

Facility has a fire clearance approval for a total of six (6) non-ambulatory residents. The facility's last fire drill was held in October, and the evacuation drill is scheduled for 2024. Facility does have a generator for emergencies if needed. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements.

LPA reviewed five (5) resident files; All resident files were found to be complete. Medications were observed, and reviewed, including PRN medication records.

LPA reviewed five (5) staff files. LPA reviewed staff training. All five(5) staff have criminal record clearance, and are associated as required. All staff had required training. All staff had current First Aid and CPR Certification.

LPA observed sufficient supply of food, perishable and non-perishable, for resident meals/snacks. Facility had sufficient furnishings for residents in care. The facility has sufficient lighting in all rooms, bathrooms, and common areas, including night lights. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed.Facility has a sufficient supply of personal protective equipment (PPE). All medications were stored/locked and inaccessible to residents in care. All cleaners/disinfectants were locked up inside the facility, and inaccessible to residents in care.