Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Primitivo Serame, DSP I & II and Cherry Serame, DSP I & II and explained the purpose of the visit. The Administrator was called on the phone who informed LPA that she is out of the area and unable to assist. The facility is licensed to care for (4) residents ages 60 and above and one may be bedridden. Bedridden fire clearance approved for bedroom #1 only. Approved to care for (4) hospice residents . LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as paper towel, hand soap and toilet paper. Staff are using appropriate hand hygiene and wearing gloves while assisting residents.

Operational Requirements: A fire clearance is in place. Facility has working signal systems in exit points. Liability Insurance policy is valid and will expire on 02/15/2026. There are (2) fire extinguishers in the facility which was last serviced on 02/18/2025.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that consists of (7) bedrooms, (3) bathrooms, living room with a fireplace, kitchen, dining area, family room, laundry area in the hallway, backyard with sitting area and attached garage. The facility is only using the bedrooms to the right of the house for residents, of which (3) bedrooms are for residents, (1) for staff, and (2) bathrooms. The other side of the house consists of 3 bedrooms dedicated as staff rooms and (1) bathroom. garage. Currently, th ere are two (2) residents in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. There are (2) carbon monoxide detectors at the home . Backyard was inspected and does not have a shaded area. There are no firearms or weapons stored at the facility. Water temperature reading measured 107.6 deg F in bathroom #1 and 109.2 deg F in bathroom #2 which is within the required 105 - 120 degrees Fahrenheit. *****REPORT CONTINUED ON LIC809-C****