Facility Evaluation Report

Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Johan "Alex" Mathews was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Johan Mathews has a valid Administrator certificate which expires on June 13, 2026. LPA began a tour of the facility and observed the following.

The facility is a two story home with five resident bedrooms, one of which is shared, one staff room, two resident bathrooms, one of which is shared, a living room, a dining room, a kitchen, and an attached two car garage. LPA observed six residents in care and two care giving staff present. LPA observed residents lounging in their respective bedrooms and in the dining room. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected the five resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed with clean linens in good repair; meaning no strains or tares, a chair, a chest of drawers, a reading lamp, and enough storage space to store personal belongings. LPA observed additional linens are stored in a closet in a resident bedroom. LPA observed Oxygen signs posted in the appropriate areas. LPA inspected resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars, slip resistant floor matts, and a shower chair. Faucets and toilets were operational. Hot water temperature measured between 114.7 and 118.6 degrees Fahrenheit. LPA observed the second story of the home is off limits to residents in care and is used for storage.

LPA observed the kitchen area to be clean and free of any mildew or debris. LPA observed for the facility to have a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed kitchen knives are stored in a locked kitchen cabinet. CONTINUED ON LIC809-C