Facility Evaluation Report

Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced site visit for the required annual inspection. Upon arrival at the facility, LPA met with Staff, Linda King, who assisted with the visit. Administrator, Hugh He, arrived shortly thereafter to join the inspection. The facility is licensed to serve a total of six (6) residents, one may be bedridden and 5 non-ambulatory ages 60 and above. The hospice waiver is approved for 1 resident. LPA utilized the infection control domain for the inspection and reviewed medications and food supplies.

The facility consists of three (3) separate units on the same lot. Each unit consists of two (2) resident bedrooms, one (1) bathroom, living room, dining room, and kitchen. There are two (2) separate garages located in the back. There are no pools or bodies of water at the location. There are five (5) residents residing at the facility on today’s visit.

During today's visit, LPA observed one bedridden resident in the front unit (940), no residents residing in the middle unit (942), and 2 residents in the back unit (944). The facility has a sign in station with masks and hand sanitizers available at each of the unit. Covid-19 signage is posted at each of the units, hand washing signage in the bathrooms and kitchen. There were at least 30 days of PPE supplies in storage. Disinfectants and cleaning solution are properly stored making them inaccessible to residents. Staff were observed wearing face masks. Two -day perishables and 7-day nonperishables were observed. LPA reviewed the medications for all five (5) residents. LPA reviewed three staff files. Administrator-Pearl He, certificate expires 08/06/2025, Hugh He certificate expires on 08/07/25. Both administrators are in process of renewing their certificates.

No deficiencies were observed on todays’, a copy of this report was provided.