Facility Evaluation Report

Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA arrived unannounced and met the Administrator, Jennifer Serrano and the LPA explained the purpose of the visit. The facility is licensed to serve 70 Ambulatory (of which 50 may be Non-Ambulatory) residents ages 60 and over. With an approved hospice waiver for 20.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. The facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.

Operational Requirements: The facility maintains a current Plan of Operation and an approved Fire Clearance. The facility maintains the required Liability Insurance.

Physical Plant & Environment Safety: This is a two-story facility includes: First Floor: Front Office, Conference Room with Storage Room and File Room, Activity Room, Storage Closets Under Parking Port, Laundry Room, Dining Hall, Kitchen, Medication Room, Linen Closet and Outdoor Patio Areas. There are 3 buildings on the first floor (A, B, F&G) totaling 16 Resident Rooms, 6 Full Bathrooms, 4 Half Bathrooms. Second Floor: 3 buildings totaling 28 Resident Rooms, 8 Full Bathrooms, 4 Half Bathrooms, Patio Area and Storage Closets. There are call buttons in and smoke detectors in each unit and there is an emergency sprinkler system throughout the facility. LPA toured facility, a total of 11 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available.