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 5 clients of which 3 can be non-ambulatory. The facility currently has 2 clients. Administrator (AD) Lommel Tumbokon was present to conduct facility tour.

LPA along with AD toured the facility at 8:25 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The facility consists of 5 client bedrooms, a living room/dining room area, exercise room, sensory room, medication room, and kitchen as well as 3 bathrooms. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client 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 111.9 degrees F and 116.7 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 alerts were operational during today's visit. LPA toured the kitchen and observed sharps locked in a box 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 infection control and emergency disaster plans and plans are complete and thorough. Facility conducts monthly emergency drills with the last drill conducted on 1/7/2025. Outside grounds were toured. Walkways around the facility were clear of hazards. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise and sensory therapy. There is shaded outdoor seating for clients. LPA observed the emergency food and water supply. LPA reviewed two client electronic files and four staff files. All electronic client files contained the required information including needs and services plans and physician reports. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. CONTINUED ON FORM LIC809-C DATED 2/19/2025