Facility Evaluation Report

This is a revised report based on 1st level Appeals Response in regards to previous annual report dated 2/18/23. Lines 13 - 17 were removed from annual report dated 2/18/23.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 02/18/2023 at 9:09 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Administrator Deborah Davis arrived shortly after and assisted in tour. Facility is licensed to residents 60 years old and above. The facility is approved for 1 bedridden and 5 non-ambulatory. The facility may retain 6 hospice residents. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020) and copy of liability insurance.

LPA OBSERVATIONS: Tour began at 9:25 am and was led by S1. The Facility is a single story building in a residential area with four (4) resident bedrooms, two (2) shared resident bathrooms, one (1) staff bedroom, one (1) staff bathroom, kitchen, dining room, living room, den/tv room, front yard, backyard and attached car garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. Kitchen sink water temperature was measured at 118.9 degrees F.

· Dining Room/Living room/Den/TV room: Dining room was observed to be clean and contained table and 5 chairs. Living room area has 2 recliners and additional seating for clients and guests. Den/Tv room was observed to be clean and contained plenty of seating.