Facility Evaluation Report

On 10/03/25, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit using the full CAREs tool. The department met with Administrator, Bessie Coello, and the purpose of today’s visit was explained. The facility is licensed to serve six (6) non-ambulatory residents, one of which may be bedridden, and an approved hospice waiver for two (2). Currently there are four (4) residents residing in the facility.

Structure/Physical Plant The facility is a two-story structure in a residential neighborhood. The facility consists of 4 bedrooms, 2 ½ bathrooms, family room, living room, kitchen, dining room, indoor activity room, outdoor activity area, laundry room, front yard, and backyard. There is a shaded patio with table and chairs. The department observed a fenced pool on the premises. All walkways around the facility were observed to be clean, clear, and free of obstructions, hazards, and debris.

Bedrooms LPA inspected all residents’ rooms and found them to be clean and in good repair. All rooms have the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. LPA observed all beds to have the required linens including a mattress cover, fitted sheets, blankets, comforter, and pillows. LPA observed an ample supply of linens in resident rooms. All bedrooms have ample lighting.

Bathrooms LPA inspected all bathrooms and found them to be within Title 22 regulations. All bathrooms were observed clean and operational. LPA observed an adequate supply of towels and personal hygiene supplies. Secured handrails and non-skid mats were observed in showers.

Kitchen LPA observed the kitchen to be clean and sanitary. All appliances were tested and found to be in good working repair. LPA observed an ample supply of cutlery, cookware, and dishware in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. A sample menu was posted on the refrigerator. All sharps were observed secured in a locked drawer in the kitchen and are inaccessible to resident. All cleaning supplies were observed secured in a locked cabinet in the activity room