Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Ivonne Lopez, caregiver for the facility, and explained the purpose of the visit. Administrator Tiffany Sasada was notified of the visit by phone call. There are five (5) residents residing within the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

· Three (3) staff did not have their medical assessment with TB clearance available for review during the annual inspection.

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, all six (6) of whom may be non-ambulatory, and a hospice waiver approved for one (1) resident. The facility consists of a kitchen, a dining room, a living room, three (3) resident bedrooms, two bathrooms of which Restroom #1 had a hot water temperature reading of 122.y Degrees Fahrenheit, and Restroom #2 which had a hot water temperature reading of 123.4 Degrees Fahrenheit, which were both over the required range of 105 – 120 Degrees Fahrenheit.