Routine inspection·July 24, 2023

At 10:00am on 07/24/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the annual facility inspection. LPA met with administrator Nellie Corrals, announced who he was and the reason for the visit. Administrator and LPA conducted a physical tour of the facility. LPA noted that there are fire detectors, carbon monoxide detector, and fire extinguisher present and all functioning within regulation requirements. LPA noted that all hallways and doors are free from obstruction and no hazards were noted. LPA noted that there are 4 bedrooms and 2 bathrooms. 3 bedrooms are double occupancy rooms and one is a staff bedroom. LPA noted that all residents bedrooms meet all regulation requirements. LPA noted that the shared bathrooms meet all regulation requirements. LPA observed at least two days of perishable foods and seven days of non-perishable foods on hand at the facility. LPA noted that the facility is clean and in good repair. LPA noted that there is a fenced front patio with table and umbrella for shade as well as a back patio with pergola for shade. LPA noted that all files and medication are located in a locked cabinet in the dinning room area. LPA could not conduct a accurate medication audit due to missing information from the Centrally Stored Medication Record which will be addressed in the Care Tool Modules and stated below. At 11:00am, Administrator and LPA conducted the Care Tools Modules review. LPA noted the following: Administrator required CPR renewal as currently working staff, which is a citation; Administrator needs additional 8 hours of continuing training for recertification renewal of Administrators Certificate, which is a citation; Medication information missing on Centrally Stored Medication Record, which is a citation; Quartlery drills not documented, which is a Technical Violation (TV) at this time. Administrator and LPA discussed the Plan of Corrections (POC) to all of the citations and TV's issued on this annual inspection. LPA will follow up on all POC's until facility compliance is met. Exit interview, report read, report singed, appeal rights report provided.