Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced for a required one year visit. The LPA met with Steve Zamarripa, Wendy McCain, and Program Director Jenn Enriquez and explained the reason for the visit. The LPA toured the physical plant to ensure there were no health and safety hazards.

KITCHEN : Knives and chemicals were kept inaccessible to clients in care. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. BEDROOMS : Bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted. RESTROOMS : Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 11:10 a.m., water temperature in the staff bathroom on the first floor measured at 107.6 F. Restrooms were fully stocked. Hand-washing signs were observed in all restrooms.

COMMON SPACES : Smoke and common monoxide detectors were tested at 11:05 a.m. and were operable at that time. Medications were locked and inaccessible in the staff room. Fire extinguisher was fully charged and serviced 3/2022. The backyard had furniture and a covered area for client use. There was an in-ground pool but it was locked and appropriately fenced at the time of the visit. The side gate was self-latching.

THERAPY AND STAFF: The LPA observed the Isolation Room, Group/Activity Room, and Staff Room on the first floor and the small group room on the 2nd f loor. The garage was designated as the Recreational Room. All rooms were clean and clear of obstructions.

INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. The facility’s cleaning protocol was sufficient. There was record of staff and resident vaccinations. The staff are up to date regarding testing, visitation and vaccine requirements. Personal Protection Equipment (PPE) supply was adequate. The facility's procedures as it pertains to infection control are adequate.

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