Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit at 12:55 p.m. The LPA met with Administrator Lorraine Medina and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals are kept inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications are locked and inaccessible in a cabinet in the kitchen. BEDROOMS: The LPA observed the three staff rooms and the four resident bedrooms. Bedrooms were observed with appropriate furnishings, clean linens and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. The Administrator was reminded to pace appropriate signs to encourage good hand hygiene in all restrooms. COMMON SPACES: Living room and dining room furniture were observed to be in good condition. The required postings were observed in the patio and throughout common spaces. The backyard has a covered outdoor area with furniture for resident use. No bodies of water were noted.

INFECTION CONTROL: The facility has a central entry point for symptom screening, temperature checks, and sanitation station. There was an adequate supply of Personal Protection Equipment (PPE) and the facility can obtain additional supplies as needed. The LPA observed hand sanitizer throughout the space for resident and staff use. This facility has documented records of staff and resident vaccinations. The LPA observed appropriate signs throughout the space that promoted good hand hygiene, signs and symptoms of COVID-19, droplet precautions, and proper mask usage. The facility’s cleaning protocol is sufficient. The Administrator is up to date with the Provider Information Notices (PINs) and regularly communicates updates to residents, staff, and responsible parties. Procedures regarding infection control are adequate.

No deficiencies were cited at this time. Exit interview conducted. A copy of the report was provided.