Facility Evaluation Report

Licensing Program Analyst (LPA) Tena Herrera arrived unannounced to conduct the required annual inspection, LPA and met with Administrator Sofi Druker, and the purpose for today’s visit was explained. The facility is licensed to serve 158 Ambulatory Residents ages 60 and over, of which 69 Residents may be Non-Ambulatory on the first floor. The facility has an approved Hospice Waiver on file for thirty (3) residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility maintains the required Infection Control Plan.

Operational Requirements: Facility maintains the required liability insurance and Surety Bond that has an expiration date of 4/1/27.

Physical Plant & Environment Safety: LPA toured facility, a total of 10 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom that were tested an operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees.

Staffing & Personnel Records-Training : There appears to be sufficient staffing at all times in the facility. Staff have criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. Administrator Sofi Druker certificate expires on 3/3/27. LPA reviewed 5 staff files with no issues.