Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA arrived unannounced and met with the house manager, Nick Baez. The initial inspection began on 9/25/25.

During the visit today, LPA inspected the remainder of the domains.

Operational Requirements: There are currently (4) residents residing at the facility. The facility has the adequate amount for liability insurance. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. Foods are properly stored in the refrigerators. Staffing : Staff employed are fingerprint cleared and associated to the facility. There is an awake staff for the overnight shift.

Personnel Records-Training : LPA reviewed the Administrator and 2 other staff files. The administrator's (Carrie Dobrenen) certificate expired on 11/15/27. Staff have current CPR & First Aid certificates and receiving annual training. Resident Records-Incident Reports: LPA reviewed 3 resident files and files contain the required documents. P&I ledgers were also reviewed. Resident Rights-Information: The Local Ombudsman and Residents personal rights information are posted at the facility. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. Incidental Medical & Dental: Medications are centrally stored and locked in the living room cabinet. LPA reviewed 3 residents' medications and no discrepancies were found. Disaster Preparedness: The facility has the updated Emergency Disaster Plan and is conducting monthly drills. Residents with Special Health Needs: There is no resident using oxygen and none with a restricted health condition.

No deficiencies issued today. An exit interview was held and a copy of this report was given to N. Baez.