Facility Evaluation Report

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 02:03 PM. LPA met with facility staff who contacted the Administrator Naira Badalyan via telephone call. The Administrator arrived to the facility at 02:17 PM. Entrance interview conducted and the reason for the visit was explained. The following was observed:

RECORD REVIEW: Record review began at 02:17 PM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Six (6) staff files were reviewed. All staff files contained the required documents and trainings. Six (6) resident files were reviewed all resident files contained all required documentation. No deficiencies were observed during record review.

MEDICATION REVIEW: Medication review began at 03:38 PM. LPA observed medications for three (3) of six (6) residents. All medications observed were documented properly on their centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 08/25/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. Continued on LIC 809C.