Facility Evaluation Report

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Sayda Naz Hai. The following 12 (CARE) tool domains were utilized during the inspection:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was observed

Facility is in a residential neighborhood and is two stories home, first floor consist of a kitchen, living room, family room, 3 resident rooms, 2 bathrooms, 1 staff room, an attached garage. The Basement is the administrator's residential area and inaccessible to the residents.

The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Cleaning supplies and toxic substances are inaccessible.

Water temperature readings measured within title 22 regulations.

A current Plan of Operation observed. Dementia Care Plan on file

A fire clearance for total 6 residents of which (5) may be Non ambulatory and (1) bedridden

Hospice care waiver approved for up to three (3) residents.

Staff have criminal background clearances.