Facility Evaluation Report

Licensing Program Analyst (LPA) Sakinah Madyun conducted an unannounced Required Annual Visit. LPA met with Licensee/Administrator Emelita Bituin, and explained the purpose of the visit. The Residential Care Facility for the Elderly is licensed to serve six (6) Non-Ambulatory residents ages 60 and above. Facility has an approved Hospice Waiver to retain/accept six (6) residents of which one (1) may be Bedridden. Currently, there are zero (0) residents in placement, zero (0) Hospice, zero (0) Bedridden (0) Exceptions, and zero (0) receiving Home Health Care. LPA did not observe residents at the time of this visit. LPA Madyun requested copies of Personnel Report (LIC 500), and Resident Roster (LIC 9020) however, due to the facility currently not having any residents or staff, no copies were provided.

Physical Plant/Environment Safety: A tour of the single-story facility began at approximately 9:30am that included residents’ rooms: one (1) private staff bedroom, three (3) semi-private bedrooms, two (2) bathrooms, living room, dining area, kitchen, and indoor/outdoor activity areas. All residents bedrooms have the required furniture for privacy, comfort, and safety; bedroom #2 was missing a chair. LPA observed the carbon monoxide detectors, fire sprinklers, and inter-connected smoke detectors with back-up battery throughout the hallway and rooms. LPA observed required auditory devices on exits. Fire extinguisher was fully charged. First-aid kit was fully stocked. LPA did not observe the Emergency Disaster Plan.

Front Yard: Was clean and well maintained without any hazards.