Facility Evaluation Report

Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff #1(S1) and explained the reason for the visit. Assistant Administrator, Karla Plata was contacted and arrived shortly after . At approximately 09:35 am, with the assistance of S1, LPA took a tour of the physical plant, and the following were observed: Required postings were observed in the entry area. The smoke alarms are interconnected and battery-operated. There are carbon monoxide detectors that function properly in the residents' rooms. The fire alarms and Carbon monoxide detectors were tested. The fire extinguisher is located in the kitchen. The charge date is March 28, 2025.

Kitchen : The kitchen appliances and fixtures were functional. LPA found a sufficient amount of properly stored perishable and non-perishable food at the facility. Knives were stored in a locked drawer in the kitchen. Bedrooms : The facility has six (6) bedrooms. There are four (4) bedrooms designated for residents' use. All four (4) bedrooms are designated for private use. There are two(2) bedrooms designated for staff use. All the bedrooms used by residents were properly furnished with appropriate bedding and linens with sufficient lighting. Bathrooms: The facility has three (3) bathrooms. There are two (2) bathrooms designated for residents' use. One (1) bathroom is designated for staff. Both bathrooms in use by residents were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 106.2 and 109.5 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas : These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. The dining room table is large enough to sit the capacity of the facility. Seating such as couches were in good repair and sat the capacity of the facility. Properly labeled medications were locked in one of the hallway cabinets. (Continue on 809C)