Facility Evaluation Report

On 1/31/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced himself, stated the purpose of the visit, and was greet by Staff (S1) Sun Sun Wai, LPA was granted entry. 4 residents were present during inspection. Administrator (A1) Marc Barcelona arrived shortly after LPA’s arrival.

LPA toured facility with A1. 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. A sample of resident’s medications were checked and observed kept locked in medication cabinet. Lisinopril 20 mg 1 tab by mouth taken twice daily, the label says once daily and MARS and Centrally Stored Medication Record says medication should be taken twice daily. Clients’ MARS was reviewed. D3 1000 1 tab taken by mouth once daily has not been signed off since 1/19/25. Fire extinguisher reviewed with a service date of: 3/26/24. Fire drill last completed on 1/7/25. Clients' bedrooms were toured and reviewed. Cleaning chemicals was observed stored and locked in facility cabinet. Resident's rooms were 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 112.6 to 115.7 degrees F in 2 bathrooms.

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 was maintained at 0 degrees F and refrigerator temperature was maintained range at 40 degrees F. Carbon monoxide were tested and observed to be operational. All clients’ files reviewed to have all the required documents. All staff files were reviewed to have all required documents.