Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 07/20/2022 to conduct a Post Licensing Inspection. LPA met with Licensee/Administrator, Babita Dhawan. Upon arrival LPA filled out a COVID screening form.

LPA toured building and grounds with Licensee/Administrator which were found to be clean and in good repair. Facility currently has 19 residents, 12 in memory care and 7 in assisted living. Facility has an approved hospice waiver for 15 residents, facility currently has 6 residents on hospice. Bedrooms were appropriately furnished. LPA measured water temperature in two locations accessible to residents. One reading was 109.7 degrees F and the second was 116.6 degrees F. Fire extinguishers inspected were last charged 04/08/2022. Carbon Monoxide detectors were observed throughout the facility. Doors are equipped with exit alarms. Facility has a sprinkler system and smoke detectors throughout the facility.

During the inspection LPA observed lunch being served in resident's bedroom as a COVID precaution. Facility is surveillance testing per CCL guidelines.

LPA reviewed 5 resident files. All resident files contained LIC 602s, Admission Agreements, and Need/Services Plans. LPA provided guidance to update admission agreements signed under previous license. LPA reviewed 4 staff files. LPA provided guidance on required staff training.

Exit interview conducted with Licensee/Administrator and a copy of the report printed for this facility.