Facility Evaluation Report

On 07/21/2025 at 9:00AM, Licensing Program Analysts (LPAs) Andrew Christy and Jill Clancy-Czuleger arrived unannounced to conduct an annual required inspection. LPAs met with administrator Corazon Casilihan and explained the purpose of the visit.

LPAs toured the facility including but not limited to the front entrance, kitchen, bathrooms, bedrooms and common areas. Inside and outside pathways were free of obstruction and fire hazards. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has medications locked in cabinets. Comfortable temperature is maintained at 71 degrees Fahrenheit. Hot water temperature was measured at 113.6 degrees Fahrenheit. Facility has an emergency disaster plan last updated 04/16/2025 as well as a mitigation plan in place. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged and last inspected on 06/17/2025 and facility last conducted a fire drill 06/30/2025. LPA reviewed 4 staff and 5 client files, all which were found to be complete.

The following citations were issued during the inspection:

1. Dresser in Room #3 was found broken and missing drawer entirely

2. MAR was missing correct documentation for dispensing of a medication.

Exit interview conducted and copy of report was provided to administrator.