Facility Evaluation Report

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Administrator Sarah Rafael. The Residential Care For Elderly (RCFE) facility serves residents ages 60 and over.

Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs).

Operational Requirements: The facility has a hospice waiver for 20 residents. A fire clearance for 100 non-ambulatory residents; of which 10 may be bedridden is in place. Facility handles resident monies and has set up trust accounts. The Surety Bond is current. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 11/1/2025. A technical advisory was issued regarding transportation van maintenance logs.

Physical Plant/Environment Safety: The facility is comprised of a 3- story building that has 66 resident rooms, 2 activity rooms, TV room, Namaste room, 3 dining rooms, laundry room, 2 courtyard patio areas, and a Memory Care Unit. The interior and exterior physical plant was inspected. A total of 18 randomly selected resident rooms were inspected. Beds have required bedding, linens, and mattress pads. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Cleaning supplies and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. Delayed egress is in place in the 1st floor Memory Care unit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. The last fire inspection was conducted on 1/24/2023 by City of San Gabriel Fire Department.