Facility Evaluation Report

At 1:10 pm, Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by staff and disclosed the purpose of the visit. The administrator was contacted. LPA Smith spoke with administrator over phone and he revealed he is out of town and not able to come to the facility. The administrator authorized staff Grace Jabalde to sign report.

LPA conducted a tour of the physical plant at approximately 1:17 pm to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the kitchen/dining room combination, living room and family room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The

kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of

perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in locked kitchen drawer. The resident medications and first aid kit stored in locked cabinet next to refrigerator and observed to be locked and inaccessible to residents. There is one (1) fire extinguisher attached to kitchen wall and observed to be charged.

Laundry room is located in walk through next to kitchen The appliances observed to be functional. Toxins stored in locked floor cabinet next to dryer and was observed to be locked and inaccessible to residents.

The facility has a total of six (6) bedrooms and two (2) bathrooms: there is one (1) shared and four (4) private bedrooms for residents and one (1) bedroom for staff.