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25 | On 1/18/2024 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Executive Director, Beronica Galindo. 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 were 11 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 and carbon monoxide detectors were present and operate on a system. Fire extinguisher last serviced 09/25/23. Last fire drill on 12/26/23. Water temperature taken and measured in 8 rooms. Water temperature varied from 110.3 to 119.2 degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Chemicals are located in chemical closet in hallways of each unit. Medications were located in locked medication carts in each hallway.
LPA requested the following documents to be submitted to CCL by 1/26/2024: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-D), 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 Executive Director, Beronica Galindo. A copy of this report was given. |