Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 9/16/25. LPA arrived unannounced and met with Administrator, Samantha Alex. The purpose of the visit was explained. The facility is licensed to serve ambulatory residents, ages 60 and above.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools and inspected the following:

Infection Control: Facility has submitted an Infection Control plan and continuing to follow the plan.

Operational Requirement: There are (5) ambulatory residents residing at the facility. The liability insurance was not provided to LPA during the visit.

Physical Plant and Environmental Safety: The facility is a single-story home consisting of (3) shared resident bedrooms, (1) staff room, (3) bathroom, 2 living rooms, dining area, kitchen. The back yard has a shaded area with table and chairs. The bathrooms required grab bar and non-skid mat. Knives and cleaning supplies are stored inaccessible to residents. There are no items obstructing the walkways.

Residents' Right : The facility has all the required postings. The facility also has internet service.

Planned Activities: The facility has sufficient space to accommodate both indoor and outdoor activities.

Food Service: The facility has sufficient food supply for two days perishable and seven days non-perishable. No residents are on a modified diet.

Disaster Preparedness: The facility has an Emergency Disaster Plan. LPA issued a technical advisory for administrator not reviewing the form annually.

Residents with Special Health Needs: There is (1) resident receiving home health services. No resident has a restricted health condition or prohibited health condition.

LPA will return another day to continue the annual inspection. A deficiency was issued today. An exit interview was held and a copy of this report, LIC809D, and appeal rights were given to the administrator.