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 Jesusa Soriano, Cook/Caregiver for the facility, and explained the purpose of the visit. Administrator Nicki Drew arrived shortly thereafter. There are five (5) 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, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for six (6) residents. The facility consists of a kitchen, a dining room, two (2) living rooms, one (1) staff bedroom, five (5) resident bedrooms, two (2) bathrooms of which restroom #1 had a hot water temperature of 110.6 Degrees Fahrenheit and restroom #2 had a hot water temperature of 105.2 Degrees Fahrenheit, along with a backyard that contains a shaded area and a detached garage. 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 two (2) fully charged fire extinguishers in the facility.

· Water temperature readings for one of the bathrooms in the home fell within the required range of 105 - 120 degrees Fahrenheit.