Facility Evaluation Report

Licensing Program Analyst (LPA) Vaid conducted an unannounced Annual Required 1-year visit. Staff person Fiviyanti Lo allowed entry into facility. LPA was met by Administrator Jasbindar Singh and explained the purpose of the visit. The facility is licensed to serve six (6) non ambulatory residents over the age of 60 and has an approved hospice waiver for four (4). Currently one(1) resident is under hospice.

The visit consisted of the completion of CARE tool, interviews of staff/residents, conduct of physical plant, and reviews of food supply/ medications/ facility records.

Physical Plant: The facility is a single-story dwelling located on a main street with three (3) resident bedrooms, two (2) staff bedrooms, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage. Front yard was clean and well maintained. LPA Vaid observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Vaid observed knives and sharps located in kitchen cabinet, to be inaccessible to residents in care. Kitchen sink water temperature was measured at 114.2 degrees F. Kitchen appliances were observed to be clean and in working order. Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. Interior temperature measured at 78 degree F. Backyard was clean and well maintained. Plenty of shade and seating was observed.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms : LPA Vaid inspected three (3) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens.