Facility Evaluation Report

On 4/17/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the caregiver and stated the reason for their visit. Facility Designee Richard Mandac arrived shortly after to assist with today’s visit.

LPA asked for the census, Staff/Resident Roster, and Liability Insurance. LPA conducted a physical plant tour at approximately 11:00 AM and the following was noted:

The facility is a single-story building with five (5) bedrooms and two (2) bathrooms currently occupying three (3) residents. There is a designated staff room and bathroom. The facility has an approved fire clearance for six (6) non-ambulatory residents of which one (1) may be bedridden. Hospice waiver for two (2). Sign in sheet, hand sanitizer, gloves and masks are available upon entrance.

Common areas: The living rooms and dining room 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. LPA observed a fire extinguisher to be located in the kitchen and dated 05/16/24. LPA observed required postings such as See/Say Something, Facility License, and Personal Rights alongside the hallway leading towards the bedrooms. 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. LPA observed an additional freezer used to store extra food located inside the garage. Knives/sharps were observed to be kept in a locked kitchen drawer. The cleaning solutions/toxins were observed to be kept locked in the hallway closet. Kitchen appliances were observed to be working and in proper condition. (continued on LIC 809-C)