Facility Evaluation Report

On today's date Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of conducting an annual inspection. Upon arrival LPA was greeted and granted entry to the facility by care giving staff. LPA explained the purpose for the visit, and Administrator (AD) Nomita Vibar was notified via phone call. AD arrived shortly after to assist LPA with annual inspection. LPA began a tour of the facility and observe the following. AD has an active Administrator certificate valid from

The facility is a single storied home with five bedrooms, one of which is a staff room and four of which are resident rooms. The facility is equipped with two bathrooms, and a detached two car garage. LPA observed kitchen area to be clean and free of any mildew and debris. LPA observed a refrigerator, gas stove, dishwasher and microwave located in the kitchen area. All appliances tested operational and appeared in good repair. LPA observed all hazards, sharps and medications to be locked away and inaccessible to residents in care. LPA observed a two day supply of perishable food and a seven day supply of non-perishable food along with a sufficient amount of emergency water on hand.

LPA observed all resident rooms to be clean and free of any mildew and debris. LPA observed all reooms to be free of any obstructions and hazards. LPA observed all rooms to be large enough to walk about freely and consist of all required furnishings including a chair, a bed, clean linens in good repair; meaning no strains or tares, a reading lamp, a chest of drawers, and enough storage space to store all personal belongings. LPA observed resident restrooms to be clean and free of any mildew and debris. LPA observed water faucets and toilets to be operational. LPA observed restrooms to have all required furnishings such as a shower chair, slip resistant matts, and grab bars. Hot water temperature tested between 104.3 and 106.5 degrees Fahrenheit. CONTINUED ON LIC809-C