Facility Evaluation Report

On 10/20/2025 Licensing Program Analyst (LPA) B. Miranda arrived to the facility unannounced to conduct annual inspection. LPA was greeted by staff Juan Moreno and allowed entry into the facility. Administrator Bhagatveer Singh was contacted and arrived at the facility shortly after.

LPA enter the facility and observed the facility to be clean, clutter free, and odor free. LPA was informed currently there is a census of 3 individuals, 2 of the individuals were home and 1 individual was visiting their family. Administrator stated the individuals do not attend program and no one has 1:1 staff.

LPA toured the facility and observed exits to be clear and free from obstructions, water from kitchen sink read at 110.8 degree Fahrenheit, fire extinguisher was last serviced 5/6/2025 and still holds charge. Smoke and carbon monoxide detector were tested and are in working order. LPA observed knives and sharps to be locked and inaccessible to residents. LPA observed the medication in the refrigerator to be unlocked and accessible to residents, other medication was locked and inaccessible to residents.

LPA reviewed staff files which are complete and up to date. LPA reviewed resident files are missing doctor orders for PRN medication for all residents. LPA observed Centrally Stored Medication Log to be incomplete and not properly maintained.

LPA observed resident bedrooms which are properly furnished with sufficient lighting. Water temperature in the resident's bathroom read at 108,5 degrees Fahrenheit. Two of the three residents have a payee for their P&I, the third resident is shown as withdrawing all monies when funds become available.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator Bhagatveer Singh