Facility Evaluation Report

An Annual visit was conducted on the date above by Licensing Program Analyst (LPA). LPA met with Assistant Administrator (AA) Elisa "Lisa" Pua. LPA spoke with Arlene Bautista by telephone. No bodies of water on the premises. Facility has a wood burning fireplace with a gas starter. Key to gas starter secured. Front of fireplace has secure glass enclosure.

Physical plant reviewed. Living & dining rooms sufficiently furnished with adequate lighting. Kitchen appeared clean & organized. Sufficient dining wear & utensils. Refrigerator & freezer appeared to be clean & sufficiently stocked. 7 day nonperishable & 2 day perishable food on the premises. Resident rooms sufficiently furnished with adequate lighting. Bathrooms fixtures operational. Grab bars in all toilet & tub/shower areas. Hallways clean & clear of any obstructions. Laundry room has combination door lock. Garage access is through laundry room. Garage contains miscellaneous items, organized with not tripping hazards. Garage has upright freezer containing additional perishable food. Appeared to be clean at sufficient temperature. Backyard has covered patio with additional seat & tables. Facility front & back yards appear to be sufficiently maintained & tidy.

Facility & Resident records reviewed including Centrally Stored Medication & Destruction Record (CSMDR) & Medication Administration Record (MARs). Medication stored in locked area & organized. Resident records appeared to be complete.

Exit interview conducted with L/A & AA. Copy of report provided.