Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection. LPA met with Administrator, Irene Imperial, and explained the reason for the visit. The facility is licensed for 6 residents, ages 60 and over, of which 5 may be non-ambulatory and 1 bedridden.

LPA used the Compliance and Regulatory Enforcement (CARE) tools and the following domains were inspected:

Infection Control: Facility has the infection control plan and staff are continuing to follow the plan. Staff are using gloves while assisting residents with their ADLs.

Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 6 residents residing at the facility. There are 2 residents on hospice. The facility has the sufficient amount for liability insurance covering injury to residents and guests.

Physical Plant & Environment Safety: The facility does not have a swimming pool on the premises. There are 3 shared resident bedrooms, 1 staff room, 2 bathrooms (1 communal and 1 in bedroom #4), living room, dining room, kitchen, and a garage. Facility has operable smoke detectors throughout the facility and a carbon monoxide detector located in the hallway. Knives, cleaning solutions, and disinfectants are locked. The hot water temperature was measured between the required range of 105-120 degrees F.

Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities.

Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable. The foods are properly stored in the refrigerator.

Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. There are no residents with a restricted or prohibited health condition at this time.

LPA will return another day to continue the inspection. No deficiencies were observed today. An exit interview was held and a copy of this report was given to the administrator.