Facility Evaluation Report

At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct an Annual Continuation Visit. Administrator, Ferdinand Alfonso, arrived at approximately 10:15AM and greeted LPA. Upon arrival, LPA was informed that 3 of 5 clients were out of the community.

During visit, LPA reviewed staff files, medication records, and conducted staff and client interviews. Medication was observed to be centrally stored and secure. First Aid and CPR certification were current for 2 of 2 staff files reviewed. Administrator's Certificate (6001350735) was current with an expiration date of 06/02/2023.

LPA requested the following documents to update facility file:

Affidavit regarding Client/Resident Cash Resources (LIC 400)

Designation of Facility Responsibility (LIC 308)

Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 5/25/2023.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.