Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrators Kian Pascual and Sheryl Tongol and discussed the purpose of the visit. The facility currently has six residents in care.

The facility is a one story home with seven bedrooms, three bathrooms, living room, dining area, kitchen, backyard, and attached two car garage. LPA observed 1 of 3 staff to not be background cleared and associated to the facility. An immediate civil penalty was assessed. LPA observed the resident bedrooms to have the required components and furnishings. LPA observed the bathrooms to have toilet paper, paper towels, and textured flooring in the shower. LPA tested the water in the bathrooms to be between 119.4-119.8 degrees Fahrenheit. LPA observed the centrally stored medication to be in a locked cabinet located in the living room. LPA observed the kitchen to be clean and free of vermin. LPA observed the knives to be in a locked drawer located by the refrigerator. LPA observed a two day perishable and seven day nonperishable food supply on hand. LPA observed the toxins and chemicals to be in a locked cabinet located in the locked garage. LPA observed the emergency food and water supply to be stored in the garage. LPA observed fire extinguishers in the dining room and garage charged and with a service date of December 3, 2024. LPA observed the backyard to have a shaded seating area for resident use. LPA observed pathways are free of obstructions.

LPA reviewed staff files and 1 of 2 staff do not have updated annual training. LPA observed resident files and 1 of 6 residents do not have a medical assessment on file, 5 of 6 residents do not have bed rail orders, and 5 of 6 residents do not have updated or signed needs and services plans. LPA observed resident medications and no discrepancies were observed. LPA observed the last fire drill to be conducted on July 5, 2025.