Facility Evaluation Report

Licensing Program Analyst (LPA) Vaid conducted an unannounced required annual inspection. LPA met with Caregiver Luz Macalisang and explained the purpose of today’s visit. Administrator Yenny Indrawati was notified and arrived shortly after.

This facility is licensed to serve three (3) non-ambulatory and three (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. Facility may retain no more than five (5) hospice residents. There are two (2) residents receiving assisted care. The facility is a single-story dwelling located in a residential neighborhood.

LPA utilized the CARE tools for the visit today and observed the following:

Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility has proof of liability insurance, and will email copy to LPA.

The 1-story facility consist of the following: 5 Resident Bedrooms and 3 Resident Bathrooms, dining room, living room, TV room, and backyard area.

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons were observed to be inaccessible to residents. Carbon monoxide detectors and smoke alarms in hallways operational. LPA inspected two (2) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in bathrooms were measured within 105 – 120 degrees F., observed grab bars near toilets. Nonskid mats and shower chair were observed. Sharps and knives are inaccessible to residents. Laundry machine working properly. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Fire extinguisher is fully charged. Continued on 809C..........