Facility Evaluation Report

Licensing Program Analyst (LPA) Angel Ascencio conducted a pre-licensing visit to the above noted

facility. The LPA met with Administrator Frances Martir at 10:30 a.m. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested and approved.

The facility is a one story home. At 10:35 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for four (4) ambulatory residents, one (1) non-ambulatory residents; and/or, one (1) bedridden residents. The facility has six (6) private resident bedrooms. All resident rooms have direct exits to the outside. Room # 1 is approved as a non-ambulatory/ bedridden room. The facility does not have fire sprinkler. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if

needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large

enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In

addition, no bedroom was used as a passageway to another room, bath or toilet. There are three (3) staff rooms within the facility. All rooms were free of odors. All window screens were clean and maintained in good repair.

There are four (4) total bathrooms. Two (2) are designated as a resident bathroom and two (2) are staff restrooms. The resident bathroom(s) have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within