Facility Evaluation Report

Licensing Program Analyst Shawna Doucette (LPA) arrived at the facility unannounced to conduct a Required Annual inspection. Staff Miguel Mendiola granted LPA entry into the facility. Staff contacted Administrator Joseph Washington who responded to the facility to assist with the visit.

LPA conducted a tour inside and outside of facility. Facility bathroom showers have an orange mildew. Facility bathroom sink water pressure is low. Hot water measured at 102.1 F. Facility was set at 73 F. Common areas were furnished well with adequate seating. Kitchen toured, and was clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Resident rooms checked. LPA observed an adequate supply of linen.

Fire extinguisher serviced on 09/24/2025. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has a pull station fire alarm and a sprinkler system. Last fire drill conducted 09/18/2025. All cleaning supplies are locked and secured in a closet in the dining room. Medications were locked in a cabinet in staff office bathroom.

Medications were reviewed. C1's centrally stored log stated C1 started medication 09/1/25 and staff logged 30 pills. On 09/29/25, pill bubble pack was popped but pill was still in the bubble pack showing C1 did not receive a medication. LPA observed two pills still in the bubble pack. Staff files and Resident files were reviewed. CPR/First aid for all staff. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching and goes out to an alley.

An exit interview was conducted with the Administrator and a copy of this report with plans of correction and appeal rights were provided.