Facility Evaluation Report

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for six bedridden residents. Facility has an approved hospice waiver for three residents and the home currently has four residents, with one resident on hospice. Administrator (AD) Mali Fakhouri assisted with the visit.

LPA along with AD toured the facility at 1:15 PM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of five resident bedrooms, staff room, living room, dining room, and kitchen, four bathrooms and an attached garage. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured 105 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in the medical closet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the emergency disaster plan and plan is complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 1/19/2026. Outside grounds were toured. Exit gates are unlocked and operational. LPA observed the water supply. First aid kit contained all required items including tweezers, scissors and thermometer. LPA reviewed four resident files and two staff files.