Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection. LPA met with the administrator, Sayda Naz Hai, and explained the purpose of the visit. The facility is licensed for six (6) residents, ages 60 and over, of which five (5) may be non-ambulatory and one (1) bedridden. There is a hospice waiver approved for (3) residents.

LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tools.

The facility has 4 bedrooms (3 resident shared bedrooms, 1 staff room), 2 bathrooms, 2 living rooms, dining room, kitchen, and attached garage. No swimming pool on the premises and no items obstructing the walkways. Smoke detectors are interconnected and carbon monoxide detectors in the hallways. LPA observed sufficient food supplies of perishable and nonperishable. Knives and cleaning solutions are locked and inaccessible to the residents. The hot water temperature is measured within the required range of 105-120 degrees F. Staff are continuing to clean and disinfect throughout the day.

LPA reviewed (3) personnel files. Administrator's certificate expires on 4/14/26. Staff are fingerprint cleared and associated to the facility. LPA issued a technical violation on staff training. LPA reviewed six (6) resident files. Files have the medical assessment, TB test results, and Needs/Services Plan. LPA reviewed medications and five (5) out of the (6) residents have medication discrepancies. The current Emergency Disaster Plan is posted and fire drills are conducted. LPA issued a technical violation to ensure that the drills are varied and properly documented.

A deficiency and technical violations are issued today. An exit interview was held and a copy of this report, along with appeal rights, was given to the administrator.