Facility Evaluation Report

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by caregiver staff and explained the reason for the visit. Administrator (AD) Arvin Bumanglag arrived shortly to assist with the visit. Facility is licensed for six non-ambulatory residents with a hospice waiver for four. Currently there are six residents, of which three are on hospice during today's visit.

LPA Tea reviewed six resident files and three staff files. Resident files and staff files for the most part contained required documentation except for one resident was missing the Personal Rights form. Administrator will have the resident’s responsible party sign the form as soon as possible. Administrator certificate expires on December, 10 2026.

LPA Tea along with AD Bumanglag toured the facility at 9:38 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of six resident bedrooms, three bathrooms, living room, dining room, staff office area, kitchen and an attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. 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 113.5 F degrees and 116.6 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, and doorways were free of obstructions. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected.