Facility Evaluation Report

Licensing Program Analysts (LPAs) Michael Tea and Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPAs were greeted and granted entry by Loida Manguray, Administrator (AD) and LPAs explained the purpose of the visit.

The facility is a two-story, six bedroom, two bathroom residence with an approved fire clearance of six non-ambulatory residents of which three may be on hospice. Staff member and an additional person live on the second floor who is not background cleared. An immediate civil penalty of $500 LIC 421BG was assessed for the additional person. The facility currently has a census of five residents in care with four on hospice. A technical violation will be given. Licensee produced email communication requesting an increase of hospice waiver to four residents. LPA advised AD and Licensee (LE) to not accept additional hospice residents until the waiver is approved and to follow-up with LPA or Licensing Program Manager (LPM) for a timely response.

During today’s visit, LPAs toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits . The hot water temperature measured 105.2 degrees Fahrenheit and all smoke detectors were operational . The fire extinguisher is charged and was serviced on April 8, 2025. The facility’s last fire drill was conducted on March 10, 2025 . Administrator was advised to conduct fire drills quarterly and a technical violation was given.