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25 | At 11:50am on 07/29/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the annual facility inspection. LPA met with Administrator, Jamie Staine, announced who he is and the reason for the visit. Tri Counties Regional Center (TCRC) Quality Assurance, Vince Figueroa (QA) was currently at the facility conducting an annual facility inspection for TCRC.
Administrator, QA and LPA toured facility The facility is maintained in conformance with state fire marshal regulations. Smoke detectors and carbon monoxide detectors functioning. Fire extinguisher was fully charged. Inside and outside passageways are free from obstruction. Facility has a backyard for resident use with furniture and shade available. The facility temperature was 70 degrees F. Hot water temperature tested was within regulation parameters. Residents’ rooms are appropriately furnished with adequate lighting. LPA observed an adequate amount of perishable and non-perishable food. Food is stored in appropriate containers in the refrigerator and freezer. A current emergency disaster and infection control plan is updated and available. Administrator is on the premises an adequate amount of hours to manage and oversee the facility. Disaster drills are conducted frequently. QA and LPA reviewed medications and Centrally Stored Medication Records (CSMR). Medications are stored in a locked cabinet. There is a signed and dated order from a physician for prescription and PRN medication. LPA reviewed a sample of client CSMR, and medications are given per physician's orders. QA and LPA reviewed client and staff files. All client files reviewed have current physicians report, current needs and services plans and admission agreements. Staff files reviewed had current first aid certificates, health screenings and adequate training hours. LPA noted that facility twin stove is broken and the kitchen counter-top at the kitchen sink is cracked, both addressed with citation on plan to repair or replaced.
Administrator and LPA conducted a full review of the annual care tools module. LPA noted that there were no citations noted during the care tools review and one citation noted in the full facility physical tour as outlined above. LPA advised Administrator to turn in change of Administrator packet as soon as possible to update current administrator.
Exit interview, one deficiency cited, appeal rights and report given.
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