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 6 ambulatory clients. The facility currently has 5 clients. Director of Operations (DO) Michael Yamashiro arrived shortly to conduct facility tour. DO provided updated liability insurance that expires on 4/21/2026.

LPA along with DO toured the facility at 1:45 PM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of 4 client bedrooms, living room, dining room, and kitchen as well as 2 bathrooms. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 111.2 degrees F and 112.2 degrees F in all bathrooms. Client 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. Perishable and non-perishable food supply was checked. Meals are delivered daily by a third party vendor. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 6/1/2025. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of outings. There is shaded outdoor seating for clients. Exit gates are unlocked and operational. LPA reviewed five client files and three staff files.