Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by the facility's caregiving staff after introducing himself and stating the reason of the visit. Administrator Arvin Bumanglag was notified via telephone and arrived later to assist with the visit.

During the inspection, LPA and staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with six private bedrooms in addition to the facility's common living areas and two attached garages. There is an additional room for use by live-in staff. There are five bathrooms including four en-suite bathrooms. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linen and blankets. Four beds are observed to be equipped with full rails and another one with half rails for postural support. Physician orders and hospice plan of care and admission reviewed for all residents on hospice. Hospice waiver capacity is six.

There are currently five residents admitted to the facility, four of which are receiving hospice care. Bathrooms faucets and toilets are operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed. Drills are conducted quarterly and documented. The copy of the Emergency and Disaster Plan provided did not include the required temporary shelter locations. A Technical Assistance Advisory Note and consultation was provided during the visit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present is fully charged and has been replaced in August 2024.

There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the property. The route of egress is free of obstructions. There are no bodies of water on the premises. CONTINUED ON FORM LIC809-C