Facility Evaluation Report

Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Bruce Chow and the facility is currently vacant with no resident reside in the facility. The facility is licensed for 6 non-ambulatory, of which one may be bedridden. Approved hospice waiver for 3.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Currently there's no resident in the facility. Facility has submitted the mitigation plan and Infection Control Plan.

Operational Requirements: Currently there's no resident in the facility. Therefore the fire clearance requirement is maintained at the present time. The facility has a Dementia Waiver Plan in place. Due to facility has no resident at the present time, the Liability insurance was not in place.

Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes kitchen, laundry room, dining area, family room, staff bathroom, three residents' rooms, living room, resident bathroom and an attached garage. All 3 resident bedrooms were toured. Each resident room has two bed, two night stand, dressers, required linen and furniture, sufficient lighting and closet space. Resident's bathroom was toured and it's clean, sanitary and in a good working condition. Bathrooms have the required grabs bars and non-skid mats. The hot water temperature was tested in resident bathroom was 110.8 degrees F which is within the Title 22 Regulation