Facility Evaluation Report

On 11/5/2025 at 12:30 PM, Licensing Program Analyst (LPA) Yasamin Brown arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Lisa Rodriquez, Director of Nursing and explained the purpose of the visit. Della DeLeon, Administrator arrived to the facility around 1:15 pm.

The administrator currently holds a certificate (#7029111740) that expires on 10/20/2026. The facility’s fire clearance was approved for thirty-one (31) residents, eight (8) may be non-ambulatory. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area, and outside area. The facility consists of four (4) buildings and nineteen (19) total bedrooms. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 75 degrees Fahrenheit.

LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 118.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and two (2) day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 4/15/2025. First aid kit was observed to be complete. LPA reviewed five (5) resident and five (5) staff files.