Facility Evaluation Report

Licensing Program Analyst (LPA) Gary Tan, met with administrator Chrysel Dela Cruz for a one (1) year required visit for this facility. Purpose of the visit was stated.

There is only one entrance being utilized at the facility. the facility had submitted and approved Mitigation and Infection Plan.

A tour of the physical plant was conducted with Ms. Dela Cruz at 12:56 PM. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. The facility is fire cleared for six (6) non-ambulatory residents, one of which maybe bedridden on Room #3. Hospice waiver for three (3) residents.

Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted:

Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. Dual smoke/carbon monoxide detector is hardwired, tested and observed to be operational. There were three (3) fire extinguishers in the facility. They are located in the kitchen, bedroom hallway and laundry room. Fire extinguishers were observed to be full and last inspected on 05/11/26.