Facility Evaluation Report

On 3/19/2026 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Mabel Itigha and explained the purpose of the visit. Staff, Madeena Siddiqi arrived an hour later.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full. One week supply of nonperishable and 2-day supply of perishable foods were available. Grab bars for each shower and toilet were installed. There were adequate lights in each room. LPA reviewed 3 residents and 3 staff records starting at 10:30AM. LPA reviewed a sample of resident's medications during inspection.

At 11:00AM, residents does not have a current appraisal needs and service (LIC625) and preplacement appraisal (LIC603) plan on file.

At 12:00PM, LPA observed unlocked medications in the refrigerator and medication cabinet was unlocked. Staff locked up the medications during inspection

At 12:05PM, LPA observed unlocked knives drawer and unlocked cleaning supplies cabinet in kitchen. Staff locked up the items during inspection.

At 12:15PM, LPA observed outdoor area has over grown weeds between the concrete pathway, tree droppings, cigarette buds, and a pile of items to be disposed. LPA also observed screen door in bedroom 6 has a couple large holes.