Facility Evaluation Report

Licensing Program Analyst (LPA) Jose Tan conducted an Annual Required visit and inspection of this facility. LPA met the Administrator Ruel Deleon and explained the reason for the visit. The facility is fire cleared for non-ambulatory residents three (3) of which may be bedridden, hospice waiver for six (6) residents. LPA conducted a physical plant tour at 9:17 AM., and observed the following:

Kitchen: LPA observed the kitchen to be clean and clear of clutter. Appliances and fixtures were functional. LPA also observed a 7 day supply of non-perishable amount of food and a 2 day supply amount of perishable food in the facility. Cleaning products were observed to be locked in a the laundry room.

Bedrooms: LPA observed a total of five (5) bedrooms designated for residents' use. One (01) bedroom may be shared. An additional one (1) bedroom and one (1) bathroom is designated for staff use. Resident bedrooms were observed clean and free of clutter, properly furnished with appropriate beds, night stands and chairs. Doors in bedrooms leading to the outside had auditory alarms that were observed functional. LPA observed night-lights through out the facility.

Bathrooms: There are two (2) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 108.3°F. and 117.1°F.

Common Areas : These included living room, and the dining area. The common areas were properly furnished. The dining area has a table with chairs to sit the capacity of the facility. The living room has a television with seating that was observed in good repair. LPA observed activities and games for the residents. (continued to LIC 809-C)