Facility Evaluation Report

Licensing Program Analyst (LPA) Lopez conducted an unannounced annual inspection visit. LPA met with Jennifer Sandoval administrator and discussed the purpose of the visit. The facility is licensed to serve four (4) non ambulatory, of which two (2) may be bedridden in Room#1, ages 60 years old and above.The facility has approved Hospice Waiver for four (4) residents. Currently, there are two (2) residents on hospice in placement. Administrator certificate is current and the expiration date is 07/22/2025

During the visit, LPA completed the physical plant domain, and toured the facility, The facility is a single-family residence located in a neighborhood, consists of two (2) bedrooms, one (1) bathroom, kitchen, dining area, laundry area, and sitting area. Passageways, walkways, entrance and patio are free from obstructions. Rooms are furnished with appropriate furniture for residents’ comfort and in compliance. The bathrooms are furnished with grab bars and nonskid surfaces.

Hot water temperature was measured between 127.0 and 127.2 degrees Fahrenheit which is not within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. Knives, tools, sharp items were inaccessible to residents. Smoke and carbon monoxide detectors were dual/hardwired and operable. Fire extinguisher was fully charged.

Deficiencies observed and cited on 809D. Due to time constraints, LPA will return another day to complete inspection.

Exit interview conducted and copy of report, 809D and appeal rights provided.