Facility Evaluation Report

On 1/29/2024 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Caregiver Pamie Palpallatoc. Licensee Donald Hay arrived at approximately 1:00 PM.

The LPA toured facility inside and outside, inspected the kitchen, living room, bathrooms, and bedrooms. All indoor and outdoor passageways were free of obstruction. LPA observed a 7 day supply of nonperishable and 2 day supply of perishable foods on hand. The LPA reviewed records of 7 residents.

2 Type-A and 1 Type-B citations were issued (for details refer to LIC809-D).

By 2/5/2024, Licensee will send updated forms to LPA:

· LIC308 - Designation of Facility Responsibility

Required Annual Inspection incomplete. LPA shall return unannounced to complete the inspection at a later date and time.

Exit interview conducted and a copy of this report provided via email to the Licensee.