Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 131 degrees Fahrenheit in client's bathroom sink, which is not the required range of 105 to 120 degrees .

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA and Med-tech observed expired medications without a back ordered replacement for R1 (photo taken). Also observed during the medication review was a bubble pack for R2 with medication pushed and re-taped, this is a medication error (Photo taken). Controlled medication count was not accurate for R3's Tramadol.

LPA reviewed 4 resident and 2 staff files, including criminal record clearances. First aid kit was checked and is complete. Fire drill was conducted on 11/03/2021.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted