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 Irina Maroussenko and explained the reason for the visit. The Administrator's Certificate expires on June 14, 2026. The facility is licensed for 6 non-ambulatory residents with a hospice waiver for 4. The facility is a single story home, with 3 bathrooms, 6 bedrooms (1 is for staff), 2 car garage, living room, laundry room dining room and kitchen. LPA and Administrator toured the facility. LPA observed the See Something, Say Something poster posted in the main entry way of the facility. LPA observed the 4 burner gas stove lights unassisted. LPA observed the kitchen has a 2 day perishable and a 7 day non-perishable food supply in the kitchen. The fire extinguisher in the kitchen is fully charged. Knives are kept locked in a box on the kitchen counter. Medication is store in a locked cart. LPA observed all resident rooms had the required furnishings and bedding. LPA observed all 3 bathrooms are clean and operational. Hot water measured 112.1 degrees Fahrenheit in all 3 bathrooms. LPA observed the garage is kept locked and used for storage. LPA observed a 3 day emergency supply of food and water stored in the garage. LPA and Administrator toured the outside of the facility. There is a table and chairs with an umbrella in the front courtyard for residents to sit outside. The backyard has two sitting areas for residents to sit outside. No bodies of water observed in the backyard. The exit gate is operational and self closing. No obstacles or hazards observed in the backyard. The last disaster drill was conducted on July 10, 2025. Smoke detectors/carbon monoxide detectors tested operational. The first aid kit has all the required elements. LPA reviewed 5 resident files and medication, no discrepancies observed. LPA reviewed 3 staff files. All 3 staff are background cleared and associated to the facility. All 3 staff have the required training and CPR. The facility has an internet device (tablet) for dedicated resident use. No deficiencies are being issued as a result of this visit. Exit interview conducted and a copy of the report provided.