Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon conducted an unannounced required annual visit. LPA met with Caregiver, Liana Wati, who contacted administrator. Assistant Administrator Robert Santamaria joined the visit at 9:45 AM. The facility serves six (6) non-ambulatory elderly residents of which one (1) may be bedridden, ages 60 and above. Facility is approved for five (5) hospice residents.

LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows:

· Resident Admission Agreements, Resident & Staff files, Staff fingerprint clearance, Medications, Staff First Aid Certificate, Resident Physician reports, resident medical consent.

· Four (4) resident bedrooms and one (1) office/staff room inaccessible to residents, two (2) bathrooms (only 1 used for residents), attached car garage, shaded outdoor area, living room, kitchen and dining room, and front and back yard.

LPA reviewed three (3) staff files and four (5) resident files. Interview was conducted with one (1) staff and one (1) resident.