Facility Evaluation Report

On March 11, 2025, Licensing Program Analyst (LPA) Rachel Bruce arrived for an unannounced required annual inspection. LPA met with Jethronel Lazaga, AD) Administrator/Licensee. AD provided tour and LPA conducted a thorough inspection and review of required documentation. Due to computer issues, LPA was unable to complete the documentation portion of the inspection using the CARE TOOLS program. Because of that, LPA had to return to issue the inspection report and close the inspection process. The time spent at the facility completing the inspection on March 11, 2025 was from 10 AM to 2:00 PM. No documentation was left at the facility on that date due to computer issues.

On March 28, 2025, LPA Bruce returned to the facility to issue the inspection report completing the annual required inspection. Below is a summary of the inspection conducted on the initial visit of March 11, 2025.

Resident rooms contained required furnishings and lighting. This facility has 6 resident bedrooms and 5 bathrooms. LPA observed required items in bathrooms with hot water measuring within the regulatory requirement range. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPA observed required food supply and paper products. Medications are centrally stored and locked in closet near the kitchen. Cleaning supplies are stored in locked laundry room. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit is located in medication storage closet and found to contain required items.

Fire Extinguishers are located throughout the facility and were serviced last on 2/20/2024. Facility has a sprinkler system. Per Licensee, Smoke and Carbon Monoxide detectors are a combo alarm and are tested annually by AAA Quality Services fire safety company, the latest inspection was conducted on 2/20/2024. The next annual appointment for testing the alarms and extinguishers is scheduled for the first week of April. LPA conducted resident and staff file reviews and found both were in compliance with regulatory requirements.