Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Licensee Eunice Kim and explained the purpose of the visit. The facility is licensed for a capacity of 6 residents, ages 60 and over, of which 2 may be non-ambulatory. There is an approved hospice waiver for 6 residents.

LPA conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed:

Infection Control: Facility staff are using appropriate hand hygiene and wearing gloves while assisting residents when necessary. Staff continue to clean and disinfect daily and more often for high touched surfaces. Facility had submitted the Infection Control Plan.

Operational Requirements: The facility accepts or retains residents with dementia. There are currently 4 residents diagnosed with dementia residing at the facility. 2 out of the 6 residents are non-ambulatory. Licensee has the sufficient amount for liability insurance that is required.

Physical Plant & Environment Safety: The facility consists of a single story building with 4 resident bedrooms, 3 bathrooms, living room, dining space, kitchen, and attached garage. The backyard has area for gardening and relaxing. There are no swimming pool or bodies of water on the premises. There are no firearms or weapons stored at the facility. There are 2 operable carbon monoxide detectors and smoke detectors throughout the facility. The hot water temperature was measured within the required range of 105-120 degrees F. The fireplace is secured by a locked gate.

Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.

Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. The facility purchases meal plans from a food vendor for lunch and dinner.