Facility Evaluation Report

On 10/08/24, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required annual inspection. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility.

LPA toured the facility inside and out. LPA observed 1 resident in care at the time of visit, other resident is currently in the hospital. Facility is a 4 bedroom, 2 bathroom home. Residents bedrooms were observed to have the required lighting and were free from any passageway obstruction / fire hazards. Facility is approved for delayed egress/locked perimeters. Bedroom 1 was malodorous and in need of cleaning and dresser needs to be replaced. Bedroom 2 is vacant. Bedroom 3 is vacant with a damaged door from a behavior and needs replacement. Bedroom 4 does not have the required furniture due to claims of property destruction. Facility temperature was 70 degrees F.

Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Doorway in Bathroom 1 is damaged from wheelchair use and is not wide enough for resident to clear. Bathroom cabinets in both bathrooms are in disrepair and need to be cleaned/painted. Floors throughout the house need to be deep cleaned. Baseboards throughout house need cleaning and/or painting. Door frames throughout the house need repair/replacing from damage done by wheelchair. Hot water temperature tested at 118 degrees F.

Medications were observed to be locked in a medication cart located in the office. Cleaning supplies were observed to be locked in the hall closet. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. Kitchen cabinets are in need of cleaning / painting. Liquid dishwasher fluid "Jet Dry" was observed unlocked under the kitchen sink. A dirty scrub brush was observed in the drawer to the left of the sink. Both were removed by Administrator at the time of the visit. LPA observed Resident R1's Restricted Health conditions plan in the facility. Carbon monoxide and smoke detectors were tested and observed to be operational. Night lights were not observed in the hallways. Fire Extinguisher was observed with a service date of 01/04/24. First aid kit was observed and contained all required items except antiseptic solution.

The exterior tour of back yard was conducted and found to be free from debris. A covered outdoor patio area was observed for residents in care, however, no seating was observed. Outdoor windows in dining area need cleaning (cobwebs). Side gate was self-closing and self-latching. Residents’ files were reviewed and observed to have update emergency contacts, Admission agreement, and current physician report/individual performance plans (IPP). LPA observed P&I records with staff and resident signatures evidencing money was given to residents. Residents are obtaining P&I monies all at once. No cash money or receipts were observed in either resident file during the inspection. A sample of staff files were also reviewed. Staff files were observed to have current First Aid/CPR. Staff are fingerprinted clear and associated to the facility.