Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a continuation of the required annual visit on 02/06/25. LPA met with staff and explained the reason for the visit. Administrator Lydia Sattiewhite arrived shortly after.

During LPA's prior visit on 2/06/2025, LPA conducted a physical plant tour, health and safety check.. During today's visit LPA conducted interviews, reviewed records and medications.

INTERVIEWS: LPA interviewed two clients during the last visit and two staff during today's visit; no concerns were voiced.

RECORDS: A review of facility files was initiated at 11:45 a.m. Facility records are stored in the locked cabinet in a supply room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 02/18/2025). The LPA obtained Client Roster, Staff Roster and Insurance liability. The LPA reviewed five(5) client files. All records were complete with pre-admission appraisals, needs and services plans, physician reports, admission agreements, and emergency contact information. The LPA reviewed five (5) staff files, All records were complete and current.

MEDICATIONS : Medications review for four (4) clients was conducted; medications are centrally stored and locked in cabinet in the supply room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

No deficiencies were observed. Exit interview conducted. A copy of the report was issued.