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 Pamela Joaquin, Caregiver for the facility, and explained the purpose of the visit. Licensee Ruby Cruz arrived shortly thereafter. There are six (6) 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 four (4) residents. The facility consists of a kitchen, a dining room, living room, one (1) staff bedroom, three (3) resident bedrooms, one (1) resident bathroom of which had a hot water temperature of 109.5 Degrees Fahrenheit, along with a backyard that contains a shaded area and an attached garage which contains extra toiletries, and food supplies 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 extinguisher in the facility.

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