Facility Evaluation Report

Licensing Program Analysts (LPAs) Bennette Pena and Gabriela Castro conducted an unannounced Required-1 year visit. LPAs were met by Marebeth Mallare, Administrator and Leonardo Mallare, Caregiver and explained the purpose of the visit. The facility cares for residents age range 60 and over and licensed for (5) non ambulatory, (1) bedridden resident (shall be in bedroom #3), and approved for (6) hospice residents only. There are currently (3) residents on hospice. LPAs 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 observed. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date.

Operational Requirements: The Infection Control Plan has been reviewed and updated. A Hospice Waiver for (6) is approved. Liability insurance policy is in place and expiring on 06/19/2025. The facility does not handle cash resources for the residents. Latest fire drill was conducted on 03/01/2025.

Physical Plant/Environment Safety: The facility is a single story home located in a residential community.

The home consists of living room, dining area, kitchen, (4) resident bedrooms, one of the bedrooms has a fireplace that is adequately screened, (4) bathrooms, back yard with swimming pool that is fenced and inaccessible to residents, and laundry area in the attached garage. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Bathrooms have the required grabs bars and non-skid materials. The laundry room is clean and has cleaning supplies inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are cleaning and are working properly. The common areas such as activity room and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. There is also a swimming pool in the backyard Exit doors have auditory devices that were operating at the time of the visit. There are cameras in the front door, backyard, living room, dining area and kitchen. There were no cameras seen in private areas. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. The facility has (3) fully charged fire extinguishers, last serviced on 01/15/2025.*****CONTINUED ON LIC809-C*****