Facility Evaluation Report

On 8/15/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff. LPA met with Executive Director, Acting Administrator Megan Mike and Resident Care Manager Melissa Segura.

LPA conducted facility tour with Administrator. All pathways, entrances and exits were clear from obstructions. The tour started in the facility common areas which were furnished with sufficient seating. The tour continued to the facility kitchen. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. At 10:16 AM LPA observed the Ice Machine to have brown buildup underneath the door lift area. LPA toured a few locked offices and storage rooms. LPA toured several resident rooms which were observed to be furnished with required furniture and adequate lighting. Bathrooms were properly equipped with non-slip mats and grab bars. Hot water temperature was tested between 117.2 degrees F and 120 degrees in several shared resident bathrooms. At 11:08 AM LPA observed Fire extinguisher in hallway to be expired with a service date of 7/20/2022. LPA toured two Locked laundry rooms. Cleaning supplies and chemicals are kept locked in hallway closet. Medications are kept locked in the Med Carts in the Medication room. Facility grounds were toured. LPA observed delayed egress doors. Doors and passageways are unobstructed throughout the facility and to the outside. LPA toured an enclosed patio area with sufficient seating and shade for recreational purposes. At 3:48 PM LPA reviewed residents’ medication with MARS and centrally stored list and observed medication count was short for one resident and over for another. LPA observed the centrally stored list was incomplete. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. It was verified that there are at least two staff on duty who are CPR certified.