Facility Evaluation Report

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual. LPA was greeted and granted entry by staff and explained the reason for the visit.

Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 2 residents and the home currently has 2 residents on hospice.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and water temperatures. The water temperatures tested at 105.6 to 110. 5 degrees. All smoke detectors were operational. The facility’s last fire drill was conducted on May 31st 2025 and has not conducted one in the current quarter of July-Sept 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed unsecured medications in kitchen cabinet. LPA observed emergency food and water in facility garage. LPA observed facility food storage in garage to have a layer of small dead insects on the bottom self where food is stored.

LPA reviewed two out of two staff training and fingerprint records, Staff 1 and Staff 2 are not associated to the facility but are background cleared. LPA reviewed all resident records and all contained the required documentation.

Based on observations made deficiencies are being cited per Title 22. An exit interview was conducted and a copy of this report, LIC 421BG, LIC 421FC and appeal rights were provided.