Facility Evaluation Report

This facility is licensed to serve three (3) non-ambulatory and 3 (3) ambulatory residents over the age of 60. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. This facility may retain no more than five (05) hospice residents. There are three (03) residents under hospice care. The facility is a single-story dwelling located in a residential neighborhood. Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection. LPA Ramirez met with Caregiver Jermin Pattiradjawane and explained the purpose of today’s visit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets. LPA Ramirez observed the following deficiencies: Smell of urine omitting from resident bedroom #5, blinds missing and broken in resident bedroom#5, resident bedroom#5 screens were observed to have dust debris all over the screen, broken and discarded fridge in backyard, bubbling, peeling and yellow-brown on ceiling in living room area, and facility dryer was observed to be in disrepair. LPA Ramirez will issue Type B deficiencies.