Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Executive Director Carla Mariano and explained the purpose for today’s visit. The facility is licensed to serve 93 Non-Ambulatory residents ages 60 and over; of which 10 may be bedridden, and an approved hospice waiver for 20.

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

Infection Control: The facility maintain the required Infection Control Plan.

Operational Requirements: The facility has an approved fire clearance and maintain the required liability insurance that has an expiration date of 8/2026.

Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and had the required closet/drawer space to accommodate each resident comfortably available. Resident rooms have signal systems located in each bathroom that were tested an operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility measured within the required range of 105-120 degrees. There are multiple shaded patio/garden areas for residents. There is a separate wing for memory care both the delayed egress and signal systems were tested and operable.

Staffing & Personnel Records-Training : There appears to be sufficient staffing at all times in the facility. Staff have criminal record clearance, current First-Aid/CPR/AED training; and training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training which are documented in personnel files. LPA reviewed 6 staff files with no issues observed. Administrator/Executive Director Carla Mariano maintains a valid Administrator certificate that expires on 4/4/26.