Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Rosario Munoz, Executive Director. The facility is licensed to serve for a capacity of 41 residents (34) ambulatory, maximum of (7) non-ambulatory restricted to Braemar cottage. Facility served elderly ages 60 and above and may retain (6) hospice residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathrooms have hygiene items such as paper towel, hand soap and toilet paper. Staff are adhering to infection control requirements.

Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan. Facility maintains the required liability insurance which expires on 03/12/2026. Surety Bond in the amount of $5000 is in effect.

Physical Plant/Environment Safety: There are 6 different cottages (Lambert, Ramona, Foskett, Shafer, Armstrong, Braemar, and Jameson) and each contains resident rooms, living room, small dining room, kitchen, and a laundry room. The main dining room and kitchen are located at the Armstrong building. LPA randomly selected resident rooms to inspect. They are clean and have the required furnishings. LPA did not observe a signal system in place. There are no items obstructing the walkways. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. No large bodies of water were observed. There are no security bars or weapons on the premises. The facility has central air and heating accommodations.The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. Storage areas for cleaning solutions, toxic, knives, and hazardous items were secured in a shed and made inaccessible to residents. The fire extinguishers were observed to be fully charged and in compliance, however some of those were not mounted on the wall. The facility has carbon monoxide detectors in each cottage. A shaded area with chairs is provided to the residents. *****CONTINUED ON LIC809-C*****