Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Yodit Gebray, Caregiver and explained the purpose of the visit. At 3:30pm, administrator Yom Tekeste arrived and assisted LPA. The facility is licensed to care for age range 60 and over. Approved for (6) non ambulatory and has an approved hospice waiver for (2). LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as paper towel, hand soap and toilet paper. Staff are trained in the proper use of required PPEs.

Operational Requirements: A fire clearance is in place. Fire Drill has not been conducted with staff yet as there are (0) residents in the facility. Facility has signal systems installed in exit points but are inoperable.

Liability insurance is valid and expires on 01/06/2027.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (4) resident bedrooms, but (1) of the bedrooms is currently being used as a staff bedroom, (4) bathrooms, (2) living rooms with fireplace, office area, kitchen, dining area, attached garage, laundry area in the garage, backyard with shaded patio area. Currently, there is (1) resident in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. Backyard was inspected and has a shaded area and sitting are a. There is (1) fire extinguisher in the facility . Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit. *****REPORT CONTINUED ON LIC809-C*****