Facility Evaluation Report

On 3/13/2025 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the caregiver and LPA stated the reason for their visit. Administrator Iveta Darabedyan arrived shortly after to assist with today’s visit.

LPA asked for the census and Staff/Resident Roster. LPA conducted a physical plant tour at approximately 11:30 AM and the following was noted:

The facility is a single unit building with five (5) bedrooms and three (3) bathrooms currently occupying three (3) residents. There is one (1) designated staff room with one (1) private bathroom. The facility has an approved fire clearance for six (6) non-ambulatory residents, one (1) of which may be bedridden. The facility has an approved Hospice waiver for six (6) residents. Sign in sheet, hand sanitizer, gloves and masks are available. LPA observed required posting such as See/Say Something, Long-Term Ombudsman, and Facility Sketch located immediately upon entrance.

Common areas: These include the living room, the dining room, and Staff Office. All rooms were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 71°F. A fireplace was observed to be covered and inaccessible to residents. A working telephone was observed.

Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Knives and sharps were observed to be kept in a locked cabinet near the kitchen stove. LPA observed cleaning solutions and toxins to be kept locked underneath kitchen sink inaccessible to residents. Kitchen appliances were observed to be working and in proper condition. LPA observed a fire extinguisher to be located near the kitchen and dated 03/13/25. (continued on LIC 809-C)