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. At around 8:00 AM, LPA Tea was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 160 non-ambulatory residents, of which 21 maybe bedridden, with a hospice waiver for 12 residents. Currently there are 67 residents and 6 are on hospice during today's visit. The Executive Directors (ED) John Goodwin and Christine Perez arrived shortly to assist with the visit.

LPA Tea reviewed eight resident files and five staff files. Resident files and staff files contained all required documentation.

At 11:20 AM LPA Tea along with ED Perez and Maintenance Director (MD) Jose Contreras-Silva toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a two-story building. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. Last disaster drill was conducted May 7, 2025. LPA observed evac chairs by the stairways in the facility for emergencies. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 105.9 Fahrenheit degrees and 107.0 Fahrenheit degrees. LPA pulled emergency pendants in resident’s bathrooms; staff came immediately within in a minute or two. Common areas were clean and clear of hazards, doorways were free of obstructions. Facility kitchen and dining area was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed