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25 | 01/28/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 6 residents in care. All residents were at day program during inspection. Upon arrival, no staff or residents were present. LPA made a call to Licensee, Mike Sus and arrived shortly after.
LPA and Licensee toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.
Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 108.0 and 110.3 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 12/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Sharps and other items that could pose threat if available to residents in care are locked in a cabinet in the office located upstairs. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Facility conducts fire and disaster drills with the last one being conducted 10/07/2024. P & I monies were documented.
LPA conducted a review of 3 resident records. All records had the required documentation. LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.
No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/28/2025:
continued on LIC809-C |