Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the facility by Kristina Zamkotidou, Staff. Staff contacted Mary Petikyan, Administrator via telephone and she arrived at 11:03am to conduct the visit. The reason for today's visit was explained.

The facility is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms, 3 full bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedroom #1 is designated for bedridden use. The facility is approved for 2 hospice waivers. There are no bodies of water on the premises.

During today's visit all 12 domains of the CARE Inspection Tool was reviewed, 5 resident files and 8 staff files were reviewed. A tour of the physical plant, inside and outside, was conducted.

The following were observed on today's visit:

The dining room, living room and kitchen are equipped/furnished with the appropriate furniture and equipment for it's designated use.

Bedroom #1 and Bedroom #4 were observed with 2 hospital beds, 2 night stands, 2 lamps, 2 chairs and a shared dresser. Bedroom #1 has 2 portable closets and Bedroom #4 has a built in closet and a portable closet. The windows and outside exiting doors have blinds for privacy. The auditory devices on the doors were tested and were operational. Located inside Bedroom #4 is a private bathroom equipped