Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon arrived at 10:45 am to conducted a 1 year annual visit to the facility above. LPA met Back up to Administrator Leticia Hernandez and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Infection Control: The facility has submitted a current Infection Control Plan. The facility has a sign in and out area for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. At 11:29 am LPA observed trash can and wastebaskets without tight fitting lids/covers. Files reviewed have some staff completing 2023 Infection control and PPE training.

Operational Requirements: The facility has a current plan of operation. The facility is approved for a capacity of 48 capacity with 48 Non-Ambulatory, which 8 may be bedridden in rooms E10, E11, E12 and E13. Facility has a current Hospice wavier granted for 27. Delayed egress has been installed on front exterior door and 3 fence gates but is not currently being used until the fire clearance is granted. Front exterior door and gates were alarmed and are not locked LPA was able to open all doors/gates. At 10:45 am LPA observed video surveillance at front entry on tour of facility LPA observed 26 cameras total all in common areas of the facility.