Facility Evaluation Report

On 03/16/2026 at 12:40 pm Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced one (1) year required visit for this facility. LPA was greeted and granted access by Administrator Linda Hughes. LPA explained the reason for the visit and an entrance interview was conducted.

Infection Control and Emergency Preparedness Plan: LPA reviewed facility Infection Control Plan and Emergency Preparedness Plan to make sure protocols are being reviewed and/or updated. Plans were discussed and updated.

A tour of the physical plant was conducted with the Administrator at 01:00 pm. The facility has three (3) bedrooms and two (2) bathrooms currently occupying four (4) clients. The facility is Fire Cleared for four (4) ambulatory. During the visit clients left to go out in the community.

Kitchen: LPA conducted a tour of the kitchen at 01:20 pm and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects locked under the kitchen sink. LPA observed the medication cabinet locked and inaccessible to residents in care. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 08/21/2025.