Facility Evaluation Report

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Victoria Dominguez and explained the reason for the visit. Marjorie Hechanova, Administrator Assistant arrived shortly thereafter.

The facility is licensed to serve residents ages sixty (60) and older, including up to six (6) non-ambulatory residents, of whom one (1) may be bedridden. Bedrooms #1, #2, and #3 are approved for non-ambulatory residents. Bedroom #4 is approved for a bedridden resident. The facility may retain no more than six (6) residents receiving hospice care. At the time of inspection, two (2) residents were receiving hospice services.

There four (4) hospice resident at the time of the visit and two (2) on home health.

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Oxygen was observed in use in the facility. Required “Oxygen in Use / No Smoking” signs were posted throughout the facility in visible locations. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

The facility is in a residential area and is a one-story home consisting of five (5) resident bedrooms, living room, kitchen, laundry room, dining area, laundry room, garage, front yard, and backyard. LPA observed five (5) resident bedrooms, and all contained the required furniture (bed, mattress, linens, dresser, chair, and lighting). Cleaning supplies and toxic substances were inaccessible to residents locked in a kitchen cabinet under sink. Bathrooms were clean and equipped with required grab bars in showers and near toilets, as well as non-skid mats; hot water measured in bathroom (1) 111.2°F, bathroom (2) 109.5°F bathroom (3) 112.3 °F and which is within the required 105–120°F. Extra linens and towels were available in a hallway cabinet. Smoke/carbon monoxide detectors were functional; fire extinguisher mounted by the living room area. There were no bodies of water present. Backyard provided shaded seating. Passageways and exits were observed to be clear and unobstructed . (continued on 809C)