Facility Evaluation Report

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Jeenne De Castro (Administrator) and explained the purpose of today's visit. The facility is licensed to serve 150 non-ambulatory residents 60 years and above. The facility has a dementia special program, delayed egress system and hospice waiver granted for 27 residents.

A tour of the single-story facility included: reception area, all common areas/rooms, 1 common restroom, 1 visitor restroom, kitchen, 7 random resident rooms, 7 random resident private bathrooms, 2 outside patios, medication room, and storage room. LPA and Jeenne De Castro toured the facility and the following was observed: the 2 outside patios are clean and there are shaded seating areas for the residents. Passageways and exits are free of obstruction. Facility has a delayed egress system in all exit doors and was operating at the time of the visit. The water temperature was tested in the 7 private residents’ bathrooms, 1 common restroom, and 1 visitor restroom and measured between at 109.2 and 119.2 degrees F, which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There are extra clean linen and towels in the resident bedroom closets. Facility has a sprinkler fire alarm system throughout the facility. Each resident bedroom has a battery operated smoke detector and carbon monoxide detector and were operating during the visit. There are battery operated carbon monoxide detectors in the all common area/rooms and were operating during the visit. There are multiple fire extinguishers throughout the facility and were last inspected on 05/17/23. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept in the kitchen and are inaccessible to the residents. Cleaning supplies and toxins are kept in a locked storage room. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. First Aid kit was fully stocked with current manual and it is kept in the medication room. Residents medication are centrally stored in the medication room. Residents and staff files are centrally stored in the administrator’s office. The signal system was tested and is operational. Fire inspection was last conducted on 03/08/2023. Fire and Disaster drill was last conducted on 05/01/2023.