Facility Evaluation Report

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced for a required one-year annual inspection. The LPA met with staff, Martina Bwalya and advised them about the visit. Staff called the Administrator Irene Saroyan, the LPA explained the reason for the visit. The Administrator informed the LPA that they were not feeling well and that they would be available via telephone if the LPA had any questions. Administrator said that staff would sign off the visit report. The LPA stated that they would call the Administrator back when the inspection was completed and would read the report to the Administrator over the phone. The LPA along with the staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 77 degrees. The smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed to be purchased on 03/11/2026. The LPA observed required postings throughout the common space. There is a working telephone on premises, however the phone number listed in the Community Care Licensing (CCL) database FAS is disconnected. The LPA advised the Administrator to update the facility number as soon as permitted through Guardian system. Working auditory alarms were observed in all exit doors at the time of the visit. Night lights were present in the hallways. The facility has a sufficient amount of emergency food and water. The LPA observed a sufficient supply of Personal Protection Equipment (PPE). LPA observed cameras in the common areas, and throughout the exterior perimeter of the facility. KITCHEN: Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps stored in a locked drawer inaccessible to residents in care. Cleaning supplies were also observed locked and inaccessible under the kitchen sink. Continues on LIC 809C...