Facility Evaluation Report

On 6/6/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Irene Pinondang, LPA was granted entry. 4 residents were present during inspection. Staff (S1) Rulet Salgado

LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Samples of resident’s medications were checked and observed. 1 resident’s medications were observed unlocked in kitchen cabinet. Clients’ MARS was reviewed. Multiple medications observed not initialed by staff on 6/6/25. Fire extinguisher reviewed with a purchase date of: 12/30/23 and does not expire for 5 years. Clients' bedrooms were toured and reviewed. Cleaning chemicals were observed stored and locked in cabinet. Residents bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 105.6 to 106.5 degrees F in 2 bathrooms. No fire drill conducted by staff.

Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature observed at 0 degrees F and refrigerator temperature maintained at 37 degrees F. Smoke detectors and carbon monoxide were tested and observed to be operational. Samples of clients’ files and staff’s files reviewed to have some required documents missing. Technical Support Services recommended and accepted by Licensee.