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25 | Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 03/28/2023 at 11:02am. LPA met with facility Administrator Griselda Galvan (Admin).
LPA toured the facility, including entryway, common room, dining room, kitchen, laundry room, 10 bedrooms, 12 bathrooms, medicine room, and activities room. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated. All residents and staff have received their booster shots as well.
Facility Mitigation plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Facility water temperature measured at 119.4*F. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to be inspected in October 2022. Smoke/carbon monoxide detectors tested and observed to be operational.
LPA interviewed 10 facility residents and 6 facility staff. 6 out of 10 residents interviewed claimed to be satisfied with facility services. 4 out of 10 residents interviewed were unable to respond to LPA questions. 6 out 6 staff interviewed demonstrated understanding of position duties. All staff members present at the facility were observed to be fingerprint cleared on Guardian. LPA reviewed 10 resident files, all resident files were observed to be complete and up to date. LPA reviewed 8 staff files. 3 out of 8 staff files were observed not to have adequate yearly training hours for 2022. Facility disaster plan and plan of operation were observed to be complete and reviewed within a year's time.
Deficiency cited during today's visit. This report was reviewed with Administrator Griselda Galvan and a copy of the signed report was provided electronically due to printer error. |