Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and was greeted by Rudolfo Macaliano (Caregiver) who allowed entrance to the facility, shortly after Evangeline De Casa (Administrator) arrived to assist with the visit, the purpose for today’s visit was explained. The facility is licensed to serve 1 6 ambulatory and 4 non-ambulatory residents ages 60 and above. There is an approved hospice waiver for 1 resident. The facility currently has 16 residents.

- The facility is a single-story home located in Bellflower, Ca. A tour of the facility consists of 2 separate units and independent rooms with private bath along the back/outside. Main unit consists of kitchen, living room, dining areas, 4 resident bedrooms, 1 staff room/storage/medication room, 1 staff office. Leading to the exterior there are 6 private units with private baths. Detached garage and storage rooms/staff break room/backup refrigerator and freezer with food. Separate unit consists of 4 bedrooms and 2 bathrooms. There is a locked laundry area and linen storage near the separate unit. Facility has a large outside activity area, back yard, front yard and parking area in back yard. There is a fire sprinkler system throughout the facility.

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

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

Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains liability insurance, however, the amount covered on aggregate was not the amount that facility is required to maintain (citation issued and will be documented on 809D). Fire Marshal arrived during visit and conducted an annual inspection with no issues.

Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. (Continued on LIC809-C)