Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 10:59 AM. LPA met with facility staff who contacted the facility Administrator Edwin Paul Oyasan. The Administrator arrived to the facility at 11:10 AM. Entrance interview conducted and the reason for the visit was explained.

During today’s visit LPA conducted a brief physical plant tour, conducted staff interviews, conducted a record/medication review, reviewed the facility’s emergency disaster plan/infection control plan, and obtained copies of the facility’s LIC 500, resident roster, and current liability insurance. The following was observed:

PHYSICAL PLANT TOUR: During the physical plant tour LPA observed the under-sink storage of the hallway bathroom to be unlocked. LPA observed this storage to contain cleaning chemicals which were unsecured and accessible to clients in care. LPA informed the Administrator who locked the storage during the inspection. The facility’s fire alarms and fire door were tested at 02:21 PM and functioned properly at the time of the inspection.

RECORD REVIEW: Record review began at 11:16 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained all required documents and trainings. Four (4) resident files were reviewed. Resident #1 (R1), resident #2 (R2)’s files were observed to be missing signed copies of the personal rights of residents. LPA informed the Administrator of the missing documents. The Administrator agreed to obtain signed copies of the missing documents. Continued on LIC 809C.