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25 | Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection on today's date of 1/11/2024. The LPA met with Administrator L. Guerrero. There are currently fifty nine (59) clients in care. Ten (10) hospice residents in compliance with licensure and fire clearance.
LPA and Administrator inspected the physical plant at approximately 11:45am to ensure the health and safety of the clients in care. LPA inspected the facility with Administrator including but not limited to the kitchen area, resident rooms, bathrooms, dining room, and storage areas. The facility had the required carbon monoxide detectors. LPA observed the facility to be free of odor and clean. LPA observed sufficient lighting throughout the facility. There are bodies of water present in the facility and they are in compliance with regulatory requirements. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA reviewed fifteen (15) client files and ten (10) staff files, including criminal record clearances. LPA observed centrally stored medications locked in then medication room. LPA reviewed and compared resident medication vs. resident medication logs at 12:50pm. Advisory given for documentation in the medication room with a request for an in-service. LPA reviewed resident and staff files, and interviewed both. All staff were cleared and associated to the facility. First aid kit was checked and is complete. No citations given.
Exit interview conducted. A copy of this report was left with the Administrator. |