Facility Evaluation Report

Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Administrator Hernand Liwanag and explained the reason for the visit.

LPA Frank toured the facility. There are 5 residents residing in the facility and one active COVID-19 case as of 5/24/22 and resident is Isolated. On 5/30/22 resident was tested COVID positive. LPA observed 1 residents on site appeared clean and well taken care of, 1 resident is admitted due to weakness, 2 residents are at the day program. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all confirmed food supply: 2 day supply of perishables and 7 day supply of

non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen

were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and

hazardous items. Medication were observed locked in cabinet.

LPA observe the facility to be clean and in good repair.

LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808)

Mitigation Plan and 3) Current Liability Insurance, Designation of Administrative Responsibility (LIC308) and

Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.

This report was discussed with the facility representative and a copy was provided.