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25 | On 3/19/2024 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Administrator, Virginia Penner. LPA introduced self, explained reason for visit and was permitted entry into the facility.
LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. There was 1 resident on hospice at the time of the inspection. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors were present and operate on a fire system. Carbon monoxide detectors present and operational at time of visit. Fire extinguisher last serviced 10/30/23. Last fire drill on 03/19/24. Water temperature measured 118 and 120 degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps, chemicals and medications were located in locked closets/rooms. LPA observed sufficient seating under covered patio areas.
LPA requested the following documents to be submitted to CCL by 3/26/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.
No deficiencies were cited during the inspection. Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with Administrator, Virginia Penner. A copy of this report was given. |