Facility Evaluation Report

Licensing Program Analyst(LPA) Sakinah Madyun and Out Of Class-Licensing Program Manager(LPM) Mary Flores conducted an annual visit. LPA and LPM met with Xia QinFen and explained the reason for the visit.

This facility is licensed to serve (49) Non- Ambulatory resident's age 60 and above. The facility may retain one bedridden resident in room#11. Hospice waiver approved for five (5) resident's. The facility consists of a single level building with (35) resident bedrooms, with private bathrooms, an activity room, chapel, laundry room, common shower area, facility kitchen and dining room area. There are (2) offices, a medication room, and a courtyard.

LPA and LPM toured the facility with Xia QinFen and observed the following:

Infection Control : Facility does not have a copy of a Infection Control Plan. All staff have a TB clearance.

Operational Requirements: Facility maintains a plan of operation and a fire clearance. Facility is operating within the limitations of their license. They have (5) resident's under hospice. A current liability insurance was observed and a copy was obtained.

Physical Plant/Environmental Safety: During facility's tour LPA and LPM observed all common areas in good repair. A total of (5) random residents' rooms were observed. Each room was furnished, with sufficient lighting, and bedding supplies, with the exception of bedroom #29 bathroom's light. Water temperature was tested in each resident's bathroom and tested between 110.0 - 122.2 degrees F., which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars and skid mats.