Facility Evaluation Report

On 12/04/2024 at approximately 09:44 am, Licensing Program Analyst (LPA), Angelica Segovia and Licensing Program Manager (LPM) Troy Agard conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by care giver Ruby Musni. LPA disclosed the reason for today’s visit. Caregiver Musni then called Administrator Eileen Maniapez who could not attend today’s visit but designated Assistant Administrator Alvin Maniapez to oversee today’s visit and sign any documentation's needed.

LPA asked for census, staff, and resident file. LPA conducted a physical plant tour at approximately 10:30 am and the following was noted:

There is only one entrance being utilized at the facility. The facility is a single unit building with four (4) bedrooms and two (2) bathrooms currently occupying five (5) residents. There is one (1) room located outside near room four (4) that is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, one of which may be bedridden in room #4. Hospice waiver for three (3) residents.

Required postings such as Facility License, Facility Sketch, and Ombudsman were located at the main entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

Common areas are neat, clean, and organized. Rooms are properly furnished and in good repair. Fireplace observed to be covered inaccessible to residents. The facility maintains a comfortable temperature at 69°F. Fire extinguisher located in the kitchen and was purchased on 10/15/24. Additional required postings were observed aside the common areas such as: Yes poster, Emergency/Disaster Plan, and Personal Rights. Along side the common areas heading towards the kitchen medication, resident, and staff files are kept locked and inaccessible to residents. (continued on LIC 809-C)