Facility Evaluation Report

At approximately 8:45 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Caregiver (CG) Isidro Diaz. CG/Back Up Administrator (BUA) Guadalupe Rivera arrived at 9:00 AM. Administrator Christine Woltering was not at the facility, but notified via telephone by the LPA at the time of the inspection. Birdie House is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a multi-story house with residents residing on the first floor only. The facility has an approved fire clearance for six (6) non-ambulatory residents. The facility has a Hospice Waiver for one (1) residents. Upon arrival, LPA was informed that there is one (1) resident in care. At approximately 9:10 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 9:15 AM, LPA toured the facility with CG/BUA Rivera. All exits were clear and unobstructed. The facility's two (2) fire extinguishers were last serviced and tagged in 4/2024. The facility was sufficiently lighted. LPA inspected three (3) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Unsecured cleaning products were observed under the kitchen sink. This deficiency will be cited. Facility has an infection control plan as required. The facility has a required emergency disaster plan. Per regulation, Emergency Disaster Drills should be held quarterly. The facility did not have an Emergency Disaster Drill log. LPA was told by CG/BUA Rivera that the last Emergency Disaster Drill was conducted in 12/2024. This deficiency will be cited.