Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Required One (1) year - Inspection to this facility and met with staff Richard "Rika" Fernando, who assisted with facility tour. At approximately 11:00AM LPA met with Administrator Fernan David to assist with the visit.

The facility is licensed to serve 6 (six) ambulatory residents ages 60 and over of which (4) may be non-ambulatory. Facility is approved to for (3) residents on hospice, currently the facility has (0) residents currently on Hospice Plan.

LPA Calderon and "Rika" toured and inspected the facility. Facility is a single story home, physical plant includes: (3) resident bedrooms and (1) staff bedroom, and (2) bathrooms, kitchen, dining, laundry area (located in the garage), an attached garage and backyard.

The bathrooms are clean and operational with grab bars and non-skid surface/mats in place. The hot water temperature was tested throughout the facility and maintained within the required range of 105-120*F.

The common areas dining room and living room were clean and properly furnished, no obstructions in pathways/ hallways.

Resident rooms are clean and were observed with appropriate bedding/ linen and furniture. Two (2) residents: Resident #1 and #3 were observed using a hospital bed and 1/2 rails, no physician report was provided, deficiency cited. Resident #2 sleeps in recliner due to personal choice.

The kitchen was observed for the ability to prepare and serve food. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. LPA observed a sufficient supply of perishables and non-perishables. Cleaning supplies and toxins are locked and are inaccessible to residents.

Temperature maintained at the house was maintained comfortable during the visit.