Facility Evaluation Report

Licensing Program Analyst (LPA) Mario Leon conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct an annual inspection. Community Care Licensing Division (CCLD) met with Evangeline Agatep - Administrator and the purpose of the visit was discussed. The facility is licensed to serve (6) non- ambulatory residents age 60 and over. Currently the facility is vendorized by Department of Health Services (DHS) Enriched Residential Care program. The facility has an approved hospice waiver for (2) residents. The facility does not handle any of the residents’ money.

This home is a one story residential home, located in a neighborhood, consisting of the following: three (3) resident bedrooms, two (2) full bathrooms, living room, kitchen/dining area, laundry area and attached garage. There is an outdoor shaded patio area. CCLD toured the resident bedrooms which had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and non-skid mats were in place, water temperature measured between 115°F through 118°F (degrees Fahrenheit), remaining within title 22 regulations. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked during the time of today's visit. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. CCLD observed 2-days worth of perishable and 7-days non-perishable food supply. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged, last maintained 04/09/26. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed.