Facility Evaluation Report

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 5/21/24. LPA arrived unannounced and met with Administrator, Maya Mnoyan. The purpose of the visit was explained. The facility is licensed for 150 non-ambulatory residents, ages 60 and over, of which (20) may be bedridden. There is a hospice waiver approved for (20) residents.

LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool. The following were observed:

Infection Control : The facility is continuing to follow their Infection Control Plan. Staff are using gloves to assist residents and performing adequate hand hygiene. Staff are receiving annual in-service training on Infection Control.

Operational Requirements : The facility is operating within the approved fire clearance. Facility accepts and retains residents with dementia. The liability insurance is current and has the sufficient amount covering the injury of residents and guests.

Physical Plant & Environment Safety : The single story facility is located in the residential area. LPA randomly selected 12 rooms to inspect as well as the common areas. The hot water temperature in the rooms was measured within the range of 105-120 degree F. The common areas are clean and furnished. Each resident room has the required furniture, closet space, and lighting. The rooms have a call cord located by the residents bed and in the bathrooms. The fireplace is not in use and adequately screened. There are no items obstructing the walkways. There is no swimming pool on the premises. The facility has smoke and carbon monoxide combo detectors that are hardwired and connected to the fire department.

Food Service : Adequate food supplies of 2 day perishable and a week of nonperishable were observed. The kitchen area is clean and free of rodents and insects. Food is properly covered to avoid contamination.

Planned Activities : Facility has a full-time Activity Director providing activities to residents. There are planned daily activities and are posted on the bulletin board.