Facility Evaluation Report

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit, and met with Staff Member, Edelyn Dacayanan . Designated Representative, Bella Nachor, arrived during visit at approximately 9:50AM. Facility has an approved fire clearance for five non-ambulatory residents and 1 bedridden resident for a total capacity of 6 residents and an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there are 5 residents in care and 3 staff members on site.

At approximately 9:15AM, LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of facility with Staff Member and observed the following: Facility is a one story residence with 5 resident bedrooms, one staff room, three bathrooms, and common areas. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. 2 of 3 facility sinks were found to be within Title 22 Regulations of 105F to 120F. One facility sink located in a resident room was measured to be 125.2F (deficiency cited, LIC809D, regulation 87303(e)(2)). There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. All resident rooms were furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguishers were inspected December 2024. Facility's smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted June 2025.