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 Elena Nueva, direct support staff for the facility, and explained the purpose of the visit. Administrator Fidelito Ruiz arrived shortly thereafter. There are five (5) residents currently living in the facility.

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.

· The facility is a single-story home located in a residential neighborhood. The facility consists of a kitchen, a dining room, a living room, two (2) staff bedrooms, an attached garage the contains the laundry area for the facility, a front yard that contains a shaded area, four (4) resident bedrooms, two bathrooms of which Restroom #1 had a hot water temperature reading of 107.6 Degrees Fahrenheit, and Restroom #2 which had a hot water temperature reading of 106.2 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 a fully charged fire extinguisher kept in the facility.