Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was

met by Farrah Siddiqui, Caregiver and explained the purpose of the visit. The co-administrator, Maria Bangash was called to inform of the visit. The facility is approved to serve residents age range 60 and above, (6) non ambulatory residents of which (1) may be bedridden. Facility is approved hospice waiver for (3) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained.

Infection control plan was developed and reviewed/updated on 07/01/2026 by the administrator. Bathroom has hygiene items such as paper towel, hand soap and toilet paper.

Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. Staff does not have the complete (12) hours of required training to provide special care to dementia residents. Facility maintains liability insurance in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate and expires on 09/18/2026.

Physical Plant/Environment Safety: The facility is a 2-story home located in a residential

neighborhood, 1st floor consists of (5) resident bedrooms, (3) bathrooms, (2) living rooms (one has a covered fireplace), (2) dining areas, kitchen, and backyard with a separate storage shed. 2nd floor consists of (4) bedrooms, (1) of which is a staff bedroom with uncovered fireplace, (2) bathrooms, laundry area. There are currently (6) residents, 60 years and older residing in the facility, (2) are under hospice care and (1) bedridden. The interior and exterior physical plant was inspected. Resident bedroom s were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. Backyard was inspected and there is a locked storage shed to house tools, garden supplies and other miscellaneous items. There is (1) unmounted fire extinguisher purchased on 02/19/2026. LPA observed a partially exposed ceiling in the downstairs hallway due to a water leak. Staff stated that a repairman has already been called and would be back to finish the work today or tomorrow. Knives, cleaning solutions, a nd disinfectants are locked. Smoke alarms and carbon monoxide were tested and operable. The facility has a video camera monitor system in the common areas. Hot water temperature reading measured within the required 105 - 120 degrees Fahrenheit (110.3 deg F in bathroom downstairs and 117.9 deg F in bathroom upstairs). *****REPORT CONTINUED ON LIC809-C*****