Facility Evaluation Report

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Hermelinda Perez about visit. As of 9/23/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility. The PUB475 "See Something, Say Something" poster was also observed at the entrance. LPA observed the Administrator's Certificate for Heremelinda Perez which expires on 10/30/22. AD Perez provided documentation to LPA De Perio that renewal fee has been submitted and courses have been completed.

LPA De Perio toured the interior and exterior portions of the facility with AD Perez. The facility is a 2 level structure and is licensed for residents 60 years and over, of which 6 may be non-ambulatory, 0 bedridden, and hospice waiver was granted for 2 hospice residents . For this visit, there are a total of 6 residents in care, of which 1 is on hospice, and 0 are bedridden. There are a total of 3 bedrooms downstairs for residents, of which there are 3 shared rooms and no private rooms. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. LPA De Perio toured second level of facility and observed no residents residing on the second floor. There are 2 bedrooms on the second floor and 1 bathroom. LPA De Perio observed and verified with AD Perez that second level is not for resident use and is utilized for AD Perez's family. LPA De Perio reviewed fingerprints and background check for live-in family members, of which both members are cleared.