Facility Evaluation Report

Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Sandra Flores and stated the purpose of todays visit. LPA was allowed entry into the facility that is licensed to serve a total capacity of 90 clients. Later Joined by Jessica Delgado.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to clients. The facility has heating equipment such as microwave, and refrigeration that was found to be in working condition and readily available for client use. The facility conducts fire and disaster drills and logged the last drill on 11/21/2025. The temperature inside the facility measured at 70 *F which is within the required range of 68-85*F. The hot water temperature was measured at 116.0 *F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility.

The first aid kit contained the required items. LPA reviewed 10 staff and 15 consumer files during this visit. During the medication review LPA observed missing PRN letters for 6 of 6 residents reviewed(copy of a sample letter was given) and centrally stored log missing entries for medications for 3 of 4 residents reviewed, also observed were outdated IPP's for 5 of 12 files reviewed (Advisories given). LPA observed missing forms for all staff files reviewed including S1 and S2. (Citation given)