Facility Evaluation Report

Licensing Program Analyst (LPA) Jose Tan conducted an Annual Required inspection of this facility today. LPA initially met with staff Leonita Garcia, who called the Administrator Claire Francisco. The Administrator arrived 10 minutes later and explained the reason for the visit.

A tour of the physical plant was conducted at 12:18 PM and the following was noted:

There is only one entrance being utilized at the facility. The facility had submitted and approved Infection Control and Mitigation plan. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has five (5) bedrooms and three (3) bathrooms currently occupying four (4) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, one of which may be bedridden on Room #5. The facility is also has an approved hospice waiver for six (6) residents.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen.

Bedrooms: All five (5) resident rooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: The bathroom for residents' use was observed to have grab bars, non-skid mats and properly supplied with hygiene products. Hot water temperature was measured at a range of 112.5°F to 112.8°F. LPA did not observe any toxins or cleaning supplies in any of the bathrooms during the day's visit. (continued on LIC 809-C)