Facility Evaluation Report

On 12/20/2021 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA Calderon was met by Administrator Raksmie Om and the purpose of today’s visit was explained. The facility is licensed to serve 4 elderly 18 to 59 years or older.

There are currently 4 residents in care. There are 4 ambulatory clients in care. The facility is a one-story

structure with 4 bedrooms and 2 bathrooms, living room, kitchen, dining room, sun room and patio/back

yard. The back yard is wide open, with fruit trees and no water sources were found.

LPA Calderon and Administrator toured the physical plant. There are no bodies of water or

firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good

condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit.. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA Calderon

observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal

hygiene, cleaning agents, toxins, and sharps were not accessible to clients and locked in a cabinet. The kitchen was inspected and there is an enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.