Facility Evaluation Report

Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced visit on 02/15/24 at 9:30 AM. LPA Campbell met with Jessica Villasenor, Team Program Lead and Administrator Vartan Hekimian and stated the purpose of the visit. This facility is licensed for 4 ambulatory residents. Bedroom #4 has been reserved for 1 non-ambulatory resident. The facility is approved for delayed egress with a secured perimeter.

LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. There was an unlocked pantry for ease of access for residents per the Team Program Lead. The hot water temperature was measured in the bathroom. The resident bathroom water temperature measured at 122 degrees, 2 degrees over the required range of 105 and 120 degrees. The facility thermostat was observed at 71 degrees Fahrenheit which is within the required range of 68 and 85 degree s. Each resident may also control the temperature in their individual room. Medication was in the staff room and was found to be locked away and inaccessible to residents. LPA Campbell observed the MAR for the facility which was found to be complete. The first aid kit was observed in the staff office.

LPA Campbell requested client and staff files for review. LPA reviewed 3 of 4 resident files and 3 of 36 staff files. Resident and staff files were complete. Toxins are stored in the laundry room and in a storage closet under lock and key. Residents may wash their own laundry during scheduled times. Detergent is dispersed as needed and returned to the locked cabinet. Otherwise, the laundry room and storage closet is locked.