Facility Evaluation Report

Licensing Program Analyst (LPA) Gary Tan conducted an Annual Required inspection of this facility today. LPA met with the administrator, Siranush Bagdasrian and explained the reason for the visit.

A tour of the physical plant was conducted at 9:01 AM and the following was noted:

There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has four (4) bedrooms and three (3) bathrooms currently occupying six (6) residents. One (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, one (1) of which may be bedridden. The facility is also has an approved hospice waiver for six (6) residents.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen.

Bedrooms: All four resident rooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: The bathrooms in use for residents were observed to have grab bars, non-skid mats and properly supplied with hygiene products. Hot water temperature was measured at a range of 116.8°F 117.4°F. LPA did not observe any toxins or cleaning supplies in any of the bathrooms during the day's visit. (continued on LIC 809-C)