Facility Evaluation Report

On 12/05/2024 at approximately 09:50 am, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by Co-Administrator Mildred Tripp and disclosed the reason for today’s visit. Manager,Teodoro Tripp, arrived shortly after where he assisted with today’s visit.

LPA asked for census, staff, and resident files. LPA conducted a physical plant tour at approximately 11:00 am and the following was noted:

There is only one entrance being utilized at the facility. The facility is a single unit building with four (4) bedrooms and three (3) bathrooms currently occupying five (5) residents. One (1) bedroom is designated for staff use and additional room is being used as an office/staff room. The facility is fire cleared for six (6) non-ambulatory residents. Hospice waiver recently approved from two (2) to six (6) residents.

Required postings such as Personal Rights, Facility Sketch, and Emergency/Disaster Plan were located at the main entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

Both living and dining rooms are neat, clean, and organized. Both rooms are properly furnished and in good repair. Fireplace observed to be properly covered and inaccessible to residents. The facility maintains a comfortable temperature at 64°F. Fire extinguisher located in hallway and last inspected on 06/03/24. Additional required postings were observed aside the kitchen such as: Yes poster and Ombudsman.

The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Knives and sharps observed to be locked in a kitchen drawer near the stove and inaccessible to residents. Cleaning solutions are kept locked in a cabinet under the sink. Stove observed to be working and in proper condition. (continued on LIC 809-C)