Facility Evaluation Report

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1 Year Inspection. LPA was greeted and granted entry by the receptionist after stating the reason for the visit. LPA was later greeted by Executive Director (ED) Zehra Syed.

The facility is licensed for 233 residents of which 75 are ambulatory, 158 non-ambulatory, and 8 may be bedridden. Facility maintains a hospice waiver approved for 15. As of today’s date, the resident census is 204 of which 7 are receiving hospice care. Facility is operating within the conditions and limitations specified on the license. The ED has a valid administrator’s certificate expiring June 7, 2028.

At or approximately 9:43am, LPA and Maintenance Director (MD) Jorge Aguirre toured the physical plant including all common areas. The facility is a three story property housing Assisted Living (AL) residents. LPA and MD observed the facility to be clean, sanitary, and in good repair. Hallways were free of clutter. LPA inspected a sample size of 10 resident units, however one resident refused the inspection for a personal reason. The resident bedrooms had all required elements with ample lighting. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and slip resistant mats were available. The hot water temperature in the resident bathrooms measured within range between 107.4-111.9 degrees Fahrenheit. LPA observed medications unsecured and accessible to residents in two units who are not authorized to manage their own medications per review of the Physician's Report (LIC602). All shared bathrooms in the common areas had sufficient supply of soap, toilet paper, and paper towels. LPA and MD inspected the kitchen and dining area. Facility maintains ample supply of two day perishables and seven day supply of non-perishable food.