Facility Evaluation Report

Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Staff#1 upon arrival. Administrator Ani Karapetyan and the facility nurse Diana Castellanos joined shortly after. LPA explained the reason of visit to Diana, the facility nurse. The annual fees are current.

The facility is licensed to serve six (6) non-ambulatory residents over the age of 60, of which six (6) may be bedridden, and has a hospice waiver for six (6) residents. The facility is a single home in a residential area and consists of a kitchen, a living/dining room, with six (6) resident rooms, two (2) bathrooms, a laundry area, a detached garage, a front yard, and a backyard. Today’s inspection consisted of applying CARE tool, conducting physical plant tour, reviewing staff/residents records, checking residents’ food supply/medication, and interviewing staff/residents.

Facility maintains an infection control plan was on file. Staff were observed practicing safe hand washing. Hand sanitizing was observed throughout. Hygiene supply and sanitizing materials were observed. Personal protective equipment was observed.

Operational Requirements: Facility maintains a plan of operation. Facility has a current liability insurance. Facility is operating within the license.

Physical Plant/Environmental Safety: Physical plant was conducted with Staff#1 (S1). Facility was observed in good repair indoors and outdoors. (-continued on LIC 809C)