Facility Evaluation Report

Licensing Program Analyst (LPA) K.Kaur conducted a Pre-licensing Inspection on this date. LPA met with

Administrator Jethronel Lazaga. A tour of the facility was conducted together.

This is an existing facility with 7 residents in placement. The facility was observed to be at a comfortable

temperature, clean, in good repair. No passageway obstructions or fire hazards were observed inside or

outside. Common areas were properly furnished and well-lit throughout. The dining room is equipped with a

table and chairs, living room is equipped with adequate sofas and recliners for residents, adequate outside

Perishable and non-perishable food supply appeared adequate. Knives will be locked in the kitchen cabinet.

Cleaning and Chemical supplies are kept in locked in the laundry room. Residents' bedrooms were observed to

be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition.

Extra linen and towels are available. Hot water temperature measured at 106 degrees F. Carbon monoxide

and smoke alarm detectors installed and operational. Grab bars installed in showers and by toilets, non-skid

mats in place, hand soap and paper towels available for use. Trash cans with tight fitting lids are in place.

Fire extinguisher was serviced on 2/15/2023 and fully charged. Medications and first aid kit are locked in the

kitchen closet. Complaint poster posted, resident council info posted, residents' rights posted, emergency

disaster plan posted. Gate is self-closing and self-latching.

Component III was also conducted and completed. Exit interview was conducted. Pre-licensing requirements

were met. An exit interview was conducted with Administrator. Report signed on-site by Administrator and