Facility Evaluation Report

Licensing Program Analyst (LPAs) Tena Herrera and Gabriela Castro conducted the required annual inspection. LPA arrived unannounced and was greeted by Maria (Caregiver) and the purpose for today’s visit was explained. Shortly after Assistant Administrator Thomas Trice arrived to assist with visit. The facility is licensed to serve 6 Non-Ambulatory residents ages 60 and above, with a hospice waiver for 2.

The facility is a single story home located in Bellflower, Ca. A tour of the facility includes: living room, dining area, kitchen, 5 resident bedrooms (1 shared room), 1 staff bedroom, 4 bathrooms (1 staff, 1 visitor, 1 resident, 1 private in room 4), laundry room, detached garage, tool shed, front yard and back yard.

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 maintains the required Infection Control Plan.

Operational Requirements: The facility maintains the required liability insurance.

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. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. Storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.

Staffing : There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency (Continued on LIC809-C)