Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Zehra Syed, Executie Director and Jessica Hernandez, Business Office Director and LPA explained the nature of the visit. Facility is licensed for 75 ambulatory, 158 non-ambulatory residents, of which 8 may be bedridden. Facility has an approved hospice waiver for 15 residents. The facility currently has 155 residents, and 6 residents are on hospice during today's visit.

LPA Martinez along with Business Office Director toured the inside and outside of the physical plant of the facility. LPA observed a bistro on the first floor where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. Facility has in storage the emergency food and water supply. Food supply delivery is done twice a week. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room on the first floor. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the first aid kit and manual stored in the medication room. There are first aid kits mounted on the walls throughout the