Facility Evaluation Report

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Gulnara Abdrakhmanova, Staff. Staff attempted to contact Breanna Kuyumchyan, Administrator but was unsuccessful and she did not participate in today's visit. Staff then contacted Eva Elizalde and she was advised by LPA Yee the reason for today's visit. Eva Elizalde arrived at 11:03am to conduct the visit.

The home is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms of which one is designated for live-in staff, 3 full bathrooms and a attached garage. The facility is fire cleared for 4 NON-AMBULATORY and 2 AMBULATORY residents. The facility is approved for 6 hospice waiver.

The following domains were reviewed and completed on today's visit: Operational Requirements, Physical Plant/Environmental Safety and partially reviewed were: Staffing, Resident Rights/Information and Residents with Special Health Needs. A return visit will be conducted to complete the inspection. A tour of the facility inside was conducted and the carbon monoxide and smoke detectors were tested and were operational.

The following was observed on today's visit:

The living room, dining room and kitchen were toured and they were equipped and furnished with the appropriate seating, furnishing and equipment for 6 residents.

Bedroom #1 was observed with 2 twin beds, a shared dresser, 2 night stands, 2 chairs with worn out covers, 2 lamps, a television and a closet. The blinds are missing slates. Per information provided, the room is for designated for staff use. Upon arrival, a resident was observed sleeping in the left bed.

the common bathroom was observed with a shower, grab bars, a single sink vanity and storage cabinets. Diapers and supplies were observed. Also observed was a can of pledge, a can of air