Facility Evaluation Report

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced required visit to the facility for the purpose of conducting the required annual inspection. LPA Rodriguez explained reason for visit and was greeted and granted entry by staff on duty. During the visit, staff on duty contacted facility administrator (AD) Hermelinda Perez about visit. For this visit, there are 2 staff members on duty, of which are background cleared and associated on Guardian.

The PUB475 "See Something, Say Something" poster was observed to be located at the entrance of the facility. LPA observed the Administrator's Certificate for Hermelinda Perez which expires on 10/30/2026.

LPA toured the interior and exterior portions of the facility with AD Perez. The facility is a two level structure and is licensed for 6 non-ambulatory residents, of which 0 may be bedridden and 4 may be on hospice. For this visit, there are a total of 6 residents in care, of which 2 are on hospice and 0 are bedridden.

On the first level, there are a total of 3 resident bedrooms, of which all 3 rooms are shared resident rooms and 2 bathrooms. LPA 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. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. On the second level, there are a total of 2 bedrooms and 1 bathroom of which is only designated for staff use. LPA observed that there are no residents or resident belongings residing on the second floor.

Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. Water temperature was measured to be at 112.9 degrees Fahrenheit.