Facility Evaluation Report

Licensing Program Analyst (LPA) Vaid conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Yanina Cota. Administrator Hugh He arrived later. The following 12 (CARE) tool domains were utilized during the inspection:

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan.

2. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, has a Dementia Waiver in place, and a Hospice Waiver for one (1) resident is approved. A fire clearance for 5 non-ambulatory and (one) 1 bedridden resident is place. Liability Insurance in the amount of at least ($1,000,000)/ occurrence and ($3,000,000) in total annual aggregate is in place and expires 7/1/2025 A surety bond is not applicable. Facility does not handle resident's money.

3. Physical Plant/Environment Safety: The facility is a single-story home located in a residential neighborhood consisting of 6 bedrooms; 5 bedrooms for residents (4 private & 1 shared) and 1 staff bedroom, 3 bathrooms, living room/ dining room, kitchen, outdoor covered patio area, laundry area is in the porch, and home has no garage. The facility has one (1) fully charged fire extinguisher 01/15/2025. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is an empty water fountain located in the backyard. Kitchen drawers containing knives/sharp objects were locked. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature in bathrooms was 119.7, 118.4, 118.9 and kitchen was 119.3 Deg F.

4.Staffing: A total of 3 caregiver staff provides care and supervision to the clients.

Due to printer issues, report will be emailed. CONTINUED ON 809C......