Facility Evaluation Report

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual visit to the facility. LPA met with Andrea Mazariego,caregiver and explained the reason for the visit.

Administrator Clemencia Bousheri was notified and arrived at the facility shortly after.

The facility is licensed to serve fifteen (15) non-ambulatory residents, ages 60 and above, and had six (6) Hospice Waiver approved. Current census is 15 residents, and 4 hospice residents.

LPA reviewed the following CARE inspection tool domains during this visit:

1.Infection Control: Infection control plan was reviewed which meets current regulations. Hand sanitizer and proper sanitation were observed during the visit. There is a responsible person and emergency training was provided for staff. Personal protective equipment was observed.

2.Operational Requirements: Facility maintains a plan of operation. Facility is operating within the license. Facility has current liability insurance, expiration 03/26/2027.

3.Physical Plant/Environmental Safety: LPA conducted a tour of the facility with Andrea Mazariego and observed the following: Facility is a single home located in a residential neighborhood. The home consists of a lobby area/ office, a kitchen, a family room, a dining room, 10 resident rooms (5 private and 5 shared rooms), 5 resident bathrooms, 1 staff bathroom, a laundry area, a front porch, a back yard consisting of the patio and garden. Facility was observed in good repair indoors and outdoors. All common areas are clean, and provide sufficient sitting area, and lighting. Kitchen area is clean; sharps were observed locked in a box. Medications were observed locked in the office. Cleaning supplies were observed to be inaccessible to residents in the laundry room. Laundry area was observed in good repair. LPA observed 6 random resident rooms, each in good repair, with all bedding supplies, and sufficient lighting. Five bathrooms were observed all in good repair, with grab bars, and non-slip shower floors.