Facility Evaluation Report

Licensing Program Analyst (LPA) Jose Villalobos arrived unannounced to conduct an Post Licensing inspection. LPA met with staff Reina Rojas who allowed entry into the home. The purpose of the visit was discussed. Administrator Hyo Kim arrived shortly after.

The Facility is licensed for six (6) residents who may be non-ambulatory, of which up to three (3) may be bedridden. Fire clearance for bedridden residents may be in Rooms #2-#4. Hospice Waiver approved for up to six (6) residents in care. Dementia care plan is in place. The inspection was completed using the CARE tools.

LPA toured and inspected a total of (9) rooms. Bedrooms #1-#6 was used for residents #1-#7 (R1-R7), Resident #8 (R8) is using the living room as their bedroom, and staff room was being used for Residents #9-10 (R9-R10). The facility is operating over its licensed capacity. LPA continued tour and observed (2) rooms used as a staff office and staff supply/break room. There are (3) bathrooms, (1) dining room, (2) living rooms, backyard with locked detached garage, and a laundry area. Sharps were observed secured in locked. The facility was free of odor, clean and in good repair. No obstructions were noted in hallways or living areas. Sufficient furniture and lighting was observed throughout the facility.

LPA reviewed plan of operation. personnel policies reviewed and discussed. Reporting requirements were discussed. This included abuse reporting procedures.

(10) Resident file records were reviewed. Resident files all had admissions agreements but missing various other documents such as physicians reports and appraisals.