Facility Evaluation Report

Licensing Program Analyst (LPA) Evelin Rios arrived to the facility above to conduct an unannounced annual required visit. LPA was greeted by a caregiver and granted access. Caregiver contacted the Licensee representative, Isaias Yin to inform him LPA was at the facility and the reason for the visit. Isaias informed LPA they would not be able to meet with LPA but would be available by telephone.

At 9:30am LPA conducted a tour of the physical plant and observed the following:

The facility is licensed for a capacity of six (6) residents. The fire clearance is approved for one (1) ambulatory resident in room #1, four (4) non-ambulatory residents in rooms #4, #5, #6, and one (1) bedridden resident in room #3. Room #4 can be shared. The facility also has a waiver granted for hospice care of two (2) residents.

At entry LPA observed a sign in sheet for visitors, thermometer, hand sanitizer and PPE supplies. LPA observed required posting through out the facility. The formal dining table sits the capacity of the facility and is in good repair. The facility keeps resident and staff records in a filing cabinet in the formal dining area. In the kitchen LPA observed there to be a sufficient supply of two-day perishable and seven-day non-perishable foods in the facility. The facility has the overflow of food stored in a second refrigerator and freezer in the garage. Food storage and preparation areas are clean and inaccessible to pests. The fire extinguisher is located in the kitchen and was last serviced on 01/07/2026. The medication and sharps were observed locked in kitchen cabinets. LPA observed a a small locked refrigerator on the kitchen counter used to store medication requiring refrigeration. LPA observed a second dining table with chairs. The living room has a television and recliners for residents. Doors leading to the outside have auditory alarms that were functioning properly. (Continue to LIC809-C)