Facility Evaluation Report

Licensing Program Analyst(s) (LPA) Jose Villalobos and Yating Yang conducted an unannounced visit for the purpose of conducting the required annual inspection focused on Infection Control Domain. LPA's met with staff Andrew De Vera, who assisted with today's visit. Administrator Yitzi Teichman arrived shortly after.

The facility is a large 2 story building with (93) client rooms licensed to serve up to (185) clients of which all are ambulatory. The overall structure is described as 2 connected buildings known as Building A and Building B. Building A houses the main lobby, medication room, kitchen, dining room and two laundry rooms. Building B consists of a quiet room, TV room, an activity room, 2 laundry rooms and 3 offices. The (93) rooms are among the first and second floor of each building. Each client room has their own bathroom. Based on the client population being served and the census, at the time of this visit, the facility is operating within the conditions and limitations specified on the license.

On todays visit LPA(s) followed the Infection control domain, toured the physical plant, reviewed ten (10) client and seven (7) staff files, and the medication records for ten (10) clients. LPA observed required amount of perishable and non-perishable food items, fully stocked first aid kit, sufficient linen supplies, hygiene supplies, security cameras located in common areas, required postings were observed. The facility has a total of 2 elevators, one in each building and were operational. Fire alarms, carbon monoxide detectors and the signalling systems are interconnected and notify the fire department when triggered. Fire panel last serviced 8/22/22. Toxins and sharps locked and inaccessible to residents. Fire extinguishers fully charged. Facility has an approved mitigation plan as of 4/24/21. Physical plant clean and free of debris. Infection control domain completed.

No deficiencies are cited at the time of this visit. Exit interview was conducted and a copy of the report provided to administrator Yitzi Teichman