Facility Evaluation Report

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced Annual/Required visit to this facility today. LPA met with Administrator Susan Park and explain the reason for the visit.

The facility has a fire clearance for 120 non-ambulatory residents 29 of which may be bedridden. Hospice Waiver for ten (10) and there is three (3) residents receiving Hospice Care at this time. The facility had submitted and approved Mitigation and Infection plan.

The facility is a single storey building located in a residential neighborhood consisting of 98 rooms. There is one (1) large activity room/living room, across the activity room is a separate area for library, activity area, pool table, computer room and a room designated for arts and crafts. It has a large dining room, laundry room, nurse's station, medication room and a basement parking.

At 9:12 AM, LPA conducted physical plant tour of the facility with the Administrator. Facility currently has 62 residents on the Assisted Living Waiver (ALW) program. Common areas, including the living room, activity room and dining room appeared to be clean and properly furnished. The kitchen appeared clean and the appliances and fixtures are functional. Refrigerated and frozen foods were stored at proper temperatures and properly packed and stored. There was a sufficient amount of perishable and non-perishable food at the facility. Residents do not have access to the kitchen; dangerous items are stored and inaccessible to residents. The facility menu appears to meet the daily dietary needs of the residents. There were no pesticides or poisons observed near any food areas. Entry/exits passages were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. (continued on LIC 809-C)