Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Sandy Lim, caregiver for the facility, and explained the purpose of the visit. Administrator Iwona Kaya arrived shortly thereafter. There are five (5) non-ambulatory residents residing within the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

· Infection control practices were observed.

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) non-ambulatory residents, and also has a hospice waiver approved for three (3) residents. The facility consists of a kitchen, laundry room, two (2) living rooms, an office, a dining room, four (4) resident bedrooms, a backyard area with a detached garage that contains the facility's emergency food supply, and two (2) resident bathrooms of which Restroom #1 (R1) had a hot water temperature reading of 105.2 degrees Fahrenheit, and Restroom #2 measured at 105.6 degrees Fahrenheit. The facility was observed to be in good repair.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has one (1) fully charged fire extinguishers in the facility.