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 Aissa Madrid, caregiver for the facility, and explained the purpose of the visit. Administrator Kevin Bim arrived shortly thereafter. There are four (4) non-ambulatory and one (1) bedridden 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) residents, one (1) of which may be bedridden and the remaining five (5) may be non-ambulatory, as well as a hospice waiver approved for three (3) residents. The facility consists of a kitchen and dining room which contains the facility’s washer and dryer machines, a living room, four (4) resident bedrooms, a backyard area, and two (2) resident bathrooms of which Restroom #1 (R1) had a hot water temperature reading of 107.4 degrees Fahrenheit, and Restroom #2 measured at 109.9 degrees Fahrenheit. The facility was observed to be in good repair.