Facility Evaluation Report

On this day Licensing Program Analysts (LPAs) Fred Arias and Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 88 non-ambulatory residents of which 10 may be bedridden. Facility has an approved hospice waiver for 15 residents and the facility currently has 67 residents, with 7 residents on hospice. Maintanance Director (MD) Pedro Ucros and Assistant Administrator (AAD) Haley Gmach arrived shortly to conduct facility tour. AAD Gmach has a valid certificate that expires on 8/10/2025. AAD provided updated liability insurance that expires on 7/01/2025.

LPAs along with MD Ucros toured the facility at 8:30 AM with AAD Gmach joining shortly after. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. 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 between 118.6 degrees F and 119.8 degrees F in checked restrooms. 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. LPAs toured the kitchen on the first floor in memory care and observed sharps in a cabinet that was not locked. Continued on LIC 809-C dated 12/23/2024.