Facility Evaluation Report

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Annual Required visit to the above facility. LPA was met by Boris and Amanda Palomino , Administrators and the purpose of today’s visit was explained.

The facility is licensed to serve (6) non-ambulatory residents ages 60 and above and hospice waiver for four (4). There are currently (1) residents on hospice.

There are currently (6) residents in the facility .

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a current Infection Control Plan.

2. Operational Requirement: Liability Insurance is updated and in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place.

3) PHYSICAL PLANT: The facility consists of 4 resident bedrooms, 3 bathrooms, kitchen, activity area, dining room, laundry room located inside the kitchen area. Adequate linen and personal hygiene supplies were observed. Medications were centrally stored, locked and inaccessible to residents in care. Auditory device alarms are operational. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. The outdoor area has a shaded area and seating. Water temperature was tested between 108.5 – 109.6 degrees F which is within the required range of 105.0 -120.0 degrees F. (continued on 809C)