Facility Evaluation Report

On 9/05/2024 at 12:00 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Benjamin Santos and explained the purpose of the visit. The facility’s fire clearance was approved for 6 residents of which 5 may be non-ambulatory with a hospice waiver for 4.

LPA toured facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. Pool observed locked and secured. A comfortable temperature is maintained at 77 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 113.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 6/26/2025. Emergency Disaster Plan was last posted on 09/05/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted in September 2024.

At 4:00 pm, LPA reviewed 5 resident records. At 4:30pm, LPA reviewed 4 staff records and 0 of 4 have current first aid training and all are associated to the facility. LPA reviewed a sample of medications and MAR.