Facility Evaluation Report

Licensing Prog ram Analyst (LPA) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by care provider Marietta Magahum after explaining the purpose of the visit. Licensee Rudy Ignacio was notified via telephone and later arrived to assist with the inspection. LPA observed the administrator certificate for Theresa Kholoma was current with an expiration date of April 28, 2027 . This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents, of which one may be bedridden, with a hospice waiver for six. The facility is a one-story home with six resident bedrooms, one staff bedroom, four bathrooms, and a garage.

During the inspection, LPA and Licensee conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

LPA observed a residents watching television in the living room and resting in their respective bedrooms. LPA observed six residents in care and two staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall in a hallway next to the entrance of the facility . All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the hallway storage closet. LPA observed bathrooms were clean and equipped with grab bars and non skid floors. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 112.4 and 115.5 degrees Fahrenheit. LPA toured the outside of the facility and observed the backyard had a shaded sitting area with furniture for resident use. LPA observed passageways leading to facility exterior exits were being used for storage. Per licensee, items will be removed and placed in the garage.