Facility Evaluation Report

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Godoyvega Escarling, staff, who assisted with the visit. Administrator, Clementia Bousheri joined the visit in 30 minutes later. The facility has a census of thirteen (13) residents. The facility is licensed to serve fifteen (15) Non-Ambulatory residents, ages 60 and above. The facility has an approved Hospice Waiver for six (6) residents on file. Currently, four (4) residents on hospice. Annual licensing fees are current. LPA discussed the purpose of today's visit with administrator.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.

The facility is a single story home located in a residential neighborhood, consisted of ten (10) resident bedrooms, six (6) bathrooms, reception area, Administrative office, living room, dining room, kitchen, TV room, sitting room, music/garden room, linen closet, laundry room, garage utilized as storage room and an indoor/outdoor activity area. Medications were centrally stored, locked and inaccessible to residents in care. Hallways were clean and free of obstructions. Common areas were well organized and free of hazards. Resident bedrooms had furniture, lighting fixtures and personal storage space as required. Mattress pads observed on all beds. The required amount of linen also observed. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature is in a range of 116.5 to 118.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. (-continued in LIC 809 C-)