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25 | Licensing Program Analyst (LPA) Loera arrived to conduct an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by staff. Administrator couldn't attend visit as they were out sick.
At approximately 9:40am, LPA and staff toured the building and grounds. Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished and free of obstructions limiting movement. Water temperature in sinks accessible to residents measured at 116.2 and 115.5 degrees F which is within the range of 105 to 120 degrees F per regulation. Refrigerated food was found to be stored in a safe manner being labeled and dated.
Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Sharps were kept in a locked box located in a locked drawer in the kitchen. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food is stored in the garage. Personal Protective Equipment is stored in the garage. Sink in kitchen was operational. Dishwasher was recently fixed and is operational. LPA observed one doorframe in a residents room to have padding with duct tape. Per conversation with staff, it's to prevent resident from hitting themselves on the doorframe. LPA observed two window screens missing in both resident bathrooms. Both toilets in the bathroom were operational with no signs indicating they did not work.
Fire extinguishers were last inspected 11/2024. Facility has smoke/carbon monoxide detectors located throughout the facility as well as a sprinkler system. Facility conducts monthly fire & emergency disaster drills with the last one being conducted 12/05/2024.
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 02/23/2025:
continued on LIC809-C |