Facility Evaluation Report

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:15 A.M. LPA met with Administrator Designee (AD) Michael Custodio. At 9:25 A.M. AD, contacted the Administrator by phone. At 9:32 A.M. LPA contacted administrator via phone and left a voicemail. At 9:38 A.M. Administrator, Francis Martit called LPA back stating that she won’t be able to join today’s visit and authorize AD to conduct today’s visit and sign reports. At 2:20 P.M. AD had to leave the facility authorizing caregiver, Jessica Leano to sign today’s report. Entrance interview conducted.

Beginning at 10:00 A.M. the LPA, along with AD toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers are fully charged and purchased on 04/08/2024. Hardwired smoke detectors and Carbon Monoxide detector were tested at 2:39 P.M. and all were functional at the time of the visit. No fire clearance concerns were observed.

KITCHEN : The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. LPA conducted a review of expiration dates on product labels. Cleaning supplies are locked and inaccessible to residents in care. Sharps are located in the medication locked cabinet. At 10:50 A.M. hot water measured 127.5 degrees Fahrenheit. AD stated that staff does not have access to a thermometer for measuring hot water. Instead, staff currently rely on using their hands to gauge the water’s heat. LPA explained that this practice does not provide an accurate reading and it is a safety risk to residents in care.