Facility Evaluation Report

Licensing Program Analyst (LPA) Daiquiri Boyd returned to the facility to complete an Annual Inspection visit. LPA was greeted by caregiver staff Hazel Flores. Staff called Administrator to come to the facility. The residence was set at 78 degrees F temperature.

LPA found obstructions of passageway in bedroom. LPA observed six bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition.

Kitchen toured. LPA did not observe adequate supply of food. Food storage was discussed for perishable fruits. Medication and knives are locked next to the kitchen area. Cleaning supplies were locked in the hallway. Smoke detectors and carbon monoxide were checked and operating. Fire extinguisher was purchased on 10/17/25. Last drill completed on 11/02/2025. There was outdoor seating for the residents.

Emergency food supply was observed and found to be adequate. There is no water on site, but staff stated it is at another facility. Staff said they will bring it to keep here. Administrator was advised to update the Emergency Disaster Plan and to post it on the wall.

A tour of the exterior of the home found the yard flooded and muddy, with no known cause.

During the visit a file review was conducted for six residents and two staff files. Hospice and home health plans were reviewed. Deficiencies were cited.

An exit interview was conducted, and a copy of this report was provided to Assistant Administrator whose signature confirms receipt.

LPA requested the following updated forms faxed to CCLD by 11/26/25: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage.