Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required Inspection and met with Licensee Nicholas Ray. Annual fees are current. Contact information was reviewed.

LPA/Licensee initiated a tour of the facility at 9:00 am. Facility passageways were free of obstruction.

Hot water temperature measured at 124.7 and 123.4 degrees F which is not within the range allowed per regulation (technical violation issued). Licensee adjusted water heater immediately. Smoke detectors and carbon monoxide was tested and operational. Two fire extinguishers were charged and serviced December 2023. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Hygiene and bedding supplies were available. Non-perishable and perishable food supply met the minimum requirements. Required postings were observed. Medications and medication records were reviewed.

-No activities were conducted during LPA's visit. LPA/Licensee discussed the importance of having activities on a regular basis (technical violation was issued).

-Last disaster drill have not been conducted within the last quarter (technical violation was issued).

-Garbage cans located in the bathrooms did not have cover to prevent the transmission of communicable disease or odors (technical violation was issued).

LPA initiated file review at 10:00 am. LPA reviewed five residents files and three staff files. Residents medical assessments and needs service plans are current. One out of three staff do not have current First Aid/CPR certificates (technical violation issued). Two out of three staff (S1 & S2) needs 20 hours of additional required training. Administrator Certificate for Nicholas Ray, 6027071740, expires on 6/24/2025.