Facility Evaluation Report

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by Staff. LPA met with Administrator Mary Yepes and explained the reason for the visit. Facility is licensed for 5 non-ambulatory residents of which 1 can be bedridden and a hospice waiver for 2. The facility is a single story home with 4 bedrooms, 2 bathrooms, living room, dining room, kitchen and a family room with a screened fireplace, laundry room and an attached two care garage. The fireplace is place is empty and the Administrator reported it is not used. The garage is kept locked and used for storage. LPA observed the PUB 475 poster posted in the living room. LPA observed all resident rooms had the required furniture. All of the resident rooms are clean and organized. How water measured 114.0 degrees Fahrenheit in both bathrooms. LPA observed the kitchen is clean and organized. Knives and sharp objects are kept locked under the kitchen sink. The fire extinguisher in the kitchen is fully charged. Medications are kept locked in a kitchen cabinet. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA and Administrator toured the backyard. There is a table and chairs in the backyard for sitting outside. The patio is covered and there is a small gazebo. LPA observed a small raised fountain. Both exit gates are operational. No obstacles or hazards observed in the backyard. Smoke detectors and carbon monoxide detectors tested operational. The last fire drill was conducted on February 19, 2026. LPA inspected the First-Aid kit, it has all the required elements. Facility has an internet device (tablet) for dedicated resident use. LPA reviewed 3 staff files, no discrepancies observed. All 3 staff are background cleared and associated to the facility. LPA reviewed 3 resident files and their medications, no discrepancies observed. LPA consulted with the Administrator concerning reporting requirements. No deficiencies observed during the visit. No deficiencies are being cited as result of this visit. An exit interview was conducted and a copy of this report and appeal rights was provided to the Facility Administrator.