Facility Evaluation Report

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Required- 1 year visit focusing on CARE TOOL . LPA was greeted by Caregiver Isajani Dadinguinoo alongside with Caregiver Delza Lim. LPA explained the purpose of the visit. The home has 6 residents at time of visit. This home is licensed to serve Elderly residents age 60 and above, (6) Non-Ambulatory of which 1 may be Bedridden and Hospice Wavier for two (2). This home is in a residential neighborhood and contains 6 bedrooms: 5 resident bedrooms, 1 staff bedroom, 2.5 bathrooms, living room, dining room, kitchen, den and a attached garage / shed. Facility has 1 resident on Hospice, and 1 Bedridden. Administrator certificate expires 05/22/24.

LPA during tour with Isajani observed PPE hygiene supplies stored in back hallway bathroom closet remains locked.

Linen/ sheets/ towels supplies in hallway closet locked.

Kitchen observed sanitary, functional equipment and sufficient, non-perishable and perishable food items for clients in care. Extra food in garage.

Hot water observed throughout the facility is within Title 22 regulation.

Toxins, disinfectants and cleaning products were observed unlocked and stored in backyard, under kitchen sink cabinet and under the 2.5 bathroom sink cabinets. Deficiencies cited, See LIC 809-D.

Resident(s) rooms have adequate furniture and is clean and sanitary. LPA observed Resident 6 (R6) bedroom cabinet missing a door. Deficiencies cited, See LIC 809-D.

No large body of water observed, no firearms on premises and 1 fireplace observed.

Outside / Backyard Ramp in disrepair, deficiencies cited, see LIC 809-D

Passageways and hallways are free of obstruction.

A posted Emergency Disaster Plan was observed , Ombudsman poster, Licensing poster, and Personal Rights were observed.

5 Staff files reviewed all cleared and have appropriate documentation's and 6 resident files were observed. Resident #1 and #6 did not have a TB report / results on file.

Smoke detector, carbon monoxide were tested and operable. Fire extinguisher was charged and serviced. Last Fire / Disaster Drill conducted on 06/02/23.

LPA Calderon conducted 1 staff interviews, 6 resident interviews.