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25 | On February 14, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:00 AM to conduct the annual 1-year required inspection. LPA Calandra met with Faimafili Igafo, Executive Director and explained the purpose of his visit.
LPA Calandra toured the physical plant. This is a two story building that consists of 180 bedrooms and 180 bathrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last inspected on September 5, 2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature were within the required range. All bedrooms were sufficiently lit and had the required furniture. The backyard was clear from obstructions. No accessible bodies of water or hazards were observed. The facility does not handle any cash resources. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit.
All knives, sharp objects, soaps, detergents, and medications were observed to be locked and in-accessible to persons in care.
A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records(CSMR) kept at the facility.
A technical violation was provided during today's visit. During a review of S1's Centrally Stored Medication Record, one Pro Re Nata (As needed)(PRN) medication was listed but could not be located.
LPA Calandra reviewed 6 staff files. All were observed to be complete.
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