Facility Evaluation Report

Licensing Program Analysts (LPAs) Mariana Agban, Angelica Segovia and Evelin Rios conducted an Annual Required visit for this facility. LPAs arrived at the facility and were granted access by Staff #1 (S1). S1 contacted the administrator designee, Stephanie Domingo. LPA Rios met with the administrator shortly after and explained the reason for the visit. The facility is licensed for a total capacity of six (6) non ambulatory residents of which one may be bedridden. Facility has a hospice waiver for six (6).

At approximately 11:40 a.m. LPAs and staff #2 (S) tour the physical plant of the facility inside and out and the following was observed:

Bedrooms: There are six (6) total bedrooms, for private use. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient lighting. Auditory alarms were observed on Exit doors and were not functioning properly in four (4) doors; two (2) emergency exit doors in two bedrooms and two (2) sliding glass doors in the living area and bedroom area.

Bathrooms: There are two (2) bathrooms. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, nonskid matts and grab bars. LPA observed night-lights in the hallway leading to the bathrooms. Hot water temperature was measured at 2:45 p.m. and read between 117 and 120 degrees Fahrenheit within regulation.

Common Areas : These included the living rooms and dining area. The common areas were clean and clear of clutter, properly furnished. The dining room table is large enough to sit the capacity of the facility. Seating such as couches where in good repair and sit the capacity of the facility. A fireplace was observed off and secured with a screen. LPA observed two (2) telephones accessible to residents.