Facility Evaluation Report

Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit.

LPA was greeted and granted entry into the facility by care staff George Agnote.

LPA Frank toured the facility. One resident residing in the facility and no active COVID-19 cases. All

resident and staff are vaccinated. LPA observed 1 resident on site and appeared clean and well

taken care of. LPA observed required department postings in the facility as well as hand washing signs in the

restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Residents bedrooms

appeared clean and sanitary and had all required components. LPA Frank tested the hot water temperature,

which measured 108.8 degrees F in resident bathroom. Resident areas were noted to be a comfortable

temperature. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency

food and water supply as well as PPE supplies. Facility has completed the LIC 808 Mitigation Plan. The

facility is still conducting COVID-19 testing as required by the latest guidance.

No citations noted during today's visit. Exit interview conducted and a copy of this report was provided.