Facility Evaluation Report

Licensing Program Analysts(LPAs) Alviso and Rummonds arrived unannounced to conduct a Required -1 Year visit, at approximately 9:30am on 8/8/23, and met with Administrator Erika Molina.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden. All smoke alarms, 10, which are also carbon monoxide detectors, were working properly during the inspection.

LPA observed a screening area by the front door to use as needed. LPAs' toured the facility. All exits were clear and unobstructed. All postings were up and visible to all as required. Fire extinguishers(3) were serviced and tagged as required- expires 6/11/24. Hot water was checked at 106.8F. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. Toxins are stored in locked cabinets, and the laundry room which contains cleaners and toxins was locked and inaccessible to residents in care. There was a sufficient supply of hygiene products, and paper products for use as needed. Medications were stored locked making them inaccessible to residents. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed.

LPA reviewed five(5) resident files. All files were complete. LPA reviewed five(5) staff files. All staff had criminal record clearance as required.