Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Administrator Sang Heng allowed the entry of the facility. The purpose for the visit was explained. The facility is licensed for AGE RANGE 60 AND OVER. 6 NON-AMBULATORY, OF WHICH 1 IS BEDRIDDEN. HOSPICE WAIVER FOR 3 . Facility has fire clearance for 6 non-ambulatory residents, one of which is bedridden. Currently there's no resident reside in the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility does not have a infection control plan in file and administrator does not have a health screening report with chest x ray and the administrator certificate is not updated.

Operational Requirement: The facility does not have any proof of liability insurance for the facility. The facility does not have at lease one person has CPR certificate.

Physical Plant and Environmental Safety: The facility includes family room, dining area, kitchen, living room, three residents rooms and two bathrooms and storage room. Currently one bathroom is renovated and the bathroom is not in a operable condition. The bathrooms also have grab bars and non-skid mat. LPA was was not able to check the hot water temperature due to the water was shut off now due to the renovation.

Staffing: Currently no staff is working at the facility.

Personnel Records-Training: The administrator (Sang Heng) certificate is expired and currently no staff is working at the facility.

Resident Records/Incident Reports: Currently facility has no residents reside and no file to be reviewed.

Residents Right Information: LPA did not observe any poster for complaint's information or resident right in the facility

Planned Activities : Currently there's no residents reside in the facility

Food Service: Currently there's no resident reside in the facility.