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25 | Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct an Annual Required - 1 Year inspection, at approximately 11:25am on 7/25/24, and met with Administrator Megan Leone.
Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved dementia plan. The facility has a hospice waiver approval for ten (10) residents.
Fire clearance is approved for one hundred and seventy-three non-ambulatory, of which 16 may be bedridden; Capacity breakdown as follows: main building, and the five (5) bungalows are cleared for one hundred and forty (140) non-ambulatory, of which six (6) may be bedridden, the memory care building is cleared for thirty-three (33) non-ambulatory, of which ten (10) may be bedridden, total license capacity is one hundred and seventy-three (173) . The delayed egress is approved, per fire clearance.
LPA reviewed nine (9) resident files. LPA reviewed nine (9) staff files. All staff had required criminal record clearance. All staff had required first aid certification, and cpr certification. All staff have required training. Medications and medication records were reviewed. Per review of the emergency disaster drills binder, the facility is completing quarterly drills as required; Fire drills held on 6/6/24, 6/11/24, and an evacuation drill held on 4/30/24.
The LPA toured the facility, main building and memory care building, with Administrator Megan and Joel Gonzalez, Business Office Director. Hot water was checked at 119.3 degrees Fahrenheit in the main building and 111. degrees Fahrenheit, which are both within regulation compliance. All exits were clear and unobstructed. Facility fire extinguishers were serviced and tagged as required. All stairwells had evacuation chairs and posted instructions for staff if needed in an emergency.
Continued on LIC809C... |