Facility Evaluation Report

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Elisabeth. LPA was informed Administrator Annet Nakiyuka was at CALA conference and Health Services Director Michelle Larrew is standing in. Facility has 42 residents with 2 residents bedridden and 7 residents on Hospice. Facility is a full dementia care.

LPA arrived at the facility and had temperature checked. LPA answered screening questions of sign-in device. Tour of facility began at approximately 11:45 am with Health Services Director Michelle Larrew and Environmental Services Director Hercules Cuevas. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 8/6/2021 at the time of the visit. Smoke Detectors & Carbon monoxide detectors were checked in February 2022 by Santa Rosa Fire Department and found to be operational. There was a sufficient amount of supply for both perishable and nonperishable foods as required. Food stored in the kitchen refrigerator was properly stored at the time of the visit. The resident bathrooms observed by LPA had required grab bars, and non-slip mat/non-slip flooring for the showers. All resident’s bedrooms have lighting & appropriate furnishings. In 9 out of 11 residents bathroom faucets hot water temperature measured between 120.3 degrees F and 124.3 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees (see LIC 809-D). Medications are kept secured as required in a locked medication room. Toxins and cleaners are kept secured in locked storage areas. Disaster drills are conducted quarterly with the last being a fire drill on 4/4/2022.

Facility has submitted a mitigation program plan that has been approved 7/13/2021. Posters have been placed at facility and entrance has electronic sign in and temperature check with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in an empty office room. All staff had masks on during this visit. Staff had all PPE training required on file and have received N-95 fit testing. All staff who are eligible to receive their COVID -19 Booster shot have.